Patient Information Sheet

Harry Ringer D.D.S.
Family & Cosmetic Dentistry
1530 Baker Street, Suite F
Costa Mesa, CA 92626
☎️ Voice: 714-545-4958
FAX: 714-276-0691
http://www.drringer.com
E-Mail: info@drringer.com
Patient Information Sheet
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver’s License
Social Security #
Spouse’s Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Please enter a valid phone number.
Phone
Please enter a valid phone number.
If patient is a minor, who is legally responsible?
Date of last dental treatment

MonthDayYear
Date
Where?
Date of last X-Rays

MonthDayYear
Date
Referred by
Family Physician
Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dental Insurance Information
Insured Member
Relationship to Patient
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer of Insured Member
Phone
Insurance Plan
Group #
SS#
Is there dual coverage?

YesNo
Subscriber Name
What Insurance Company?
Are you a full time student?

YesNo
Where?
I hereby grant authority to HARRY RINGER, D.D.S., and/or to the dentist(s) in charge of my care, to administer any treatment, to administer such anesthetics; and to perform such operations as may be deemed necessary in the diagnosis and treatment of my case. I authorize the taking of radiographs, photographs, or other diagnostic aids as needed for a thorough evaluation.

I acknowledge that I have been informed of the risks and possible consequences of the operation/s proposed and do authorize the above-named doctor(s) to proceed, and will assume financial responsibility.
Signed
Patient, Parent or Guardian
Date

MonthDayYear
Patient or legal guardian in the case when the patient is a minor or physically or mentally incompetent.

Medications
Date

MonthDayYear
Medication
Purpose
Frequency