www.vlfamilydentistry.com - Patient Information

Patient Information
Today’s Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Preferred
Family Status
If "Other" please explain*
Title
If "Other" please explain*
Gender
Patient Birthdate

MonthDayYear
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
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E-mail*
example@example.com
Preferred Method of Confirmation

TextE-mailPhone calls
Previous Dentist
Previous Dentist Phone Number
Please enter a valid phone number.
Referred to our office by
Emergency Contact
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Responsible Party Information
Responsible Party Information
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Employer’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Primary Dental Insurance Information
Name of Insured
Insured’s Birthdate

MonthDayYear
SSN
ID Number
Group Number
Insured’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient’s Relationship to Insured
If "Other" please explain
Insured’s Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Plan Name
Insurance Address
Do you have secondary dental insurance?*

YesNo
Secondary Dental Insurance Information
Name of Insured
Insured’s Birthdate

MonthDayYear
SSN
ID Number
Group Number
Insured’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient’s Relationship to Insured
If "Other" please explain
Insured’s Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Plan Name
Insurance Address
I AUTHORIZE RELEASE OF ANY INFORMATION RELATING TO MY INSURANCE AND ASSIGN PAYMENT OF DENTAL BENEFITS TO THE ABOVE NAMED PROVIDER.
Signed Patient or Guardian*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Patient Information

Emergency Contact

Responsible Party Information

Primary Dental Insurance Information

Secondary Dental Insurance Information