Patient Information Form

Valley Smiles A Appreach
PATIENT INFORMATION
COMPLETION OF THIS FORM IN ITS ENTIRETY IS REQUIRED AT TIME OF VISIT/TREATMENT
Name
Birthdate

MonthDayYear
Date
Age
Gender
Social Security No.
Address

Home Address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone
Email
example@example.com
How would you like your confirmation sent?
How were you referred?
Employed by
Occupation
Work Phone No.
IN CASE OF EMERGENCY
Spouse/Parent
Phone
Address
Another relative
Phone
Address
Person not Related
Phone
Address
Physician Name
Phone
Specialty
INSURANCE INFORMATION-If no insurance check here
If no insurance how to you intend to pay?
PRIMARY
Subscriber's Name
Birthdate

MonthDayYear
Date
Subscriber ID No
How is patient related to subscriber?
Insurance Name
Address
SECONDARY
Subscriber's Name
Birthdate

MonthDayYear
Date
Subscriber ID No
How is patient related to subscriber?
Insurance Name
Address
Name of responsible party
Relationship to patient
Address

Home Address

Street Address Line 2

CityState

Zip
Main Phone
Work Phone
Email
example@example.com
Name of person who can authorize treatment
Phone No.
I understand and acknowledge that I am financially responsible for the services provided for myself (or the above named) regardless of insurance coverage.
Signature of responsible party

Clear
Date

MonthDayYear
Date
Should be Empty:

Valley Smiles A Appreach