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 Name Middle Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / 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

City
Driver’s License
Social Security #
Spouse’s Name
Address

Street Address

Street Address Line 2

City State / 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

City
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

Month Day Year
Date
Where?
Date of last X-Rays

Month Day Year
Date
Referred by
Family Physician
Address

Street Address Line 2

Dental Insurance Information
Insured Member
Relationship to Patient
Address

Street Address Line 2
Employer of Insured Member
Phone
Insurance Plan
Group #
SS#
Is there dual coverage?

Yes No
Subscriber Name
What Insurance Company?
Are you a full time student?

Yes No
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

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

Medications
Date

Month Day Year
Medication
Purpose
Frequency

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