New Patient Form

New Patient Form

Info@Hamilton-Smiles.com | 919-870-4443
Date

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Are you completing this form for yourself or on behalf of someone else?*

I'm completing this form for myself.I'm completing this form on behalf of someone else. (I'm the parent, guardian, or power of attorney)

Responsible Party Information
Responsible Party #1
First Name *
Last Name*
Middle Initial
Relationship to Patient*
Employer/Occupation
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Responsible Party #1 Social Security Number
For Insurance purposes
Marital Status
Would you like to add a second responsible party?*

YesNo

Responsible Party #2

If applicable
First Name
Last Name
Middle Initial
Relationship to Patient
Employer/Occupation
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Responsible Party #2 Social Security Number
For Insurance purposes
Marital Status

Primary dental/orthodontic concerns*

Please upload photos of the front and back of your insurance card so we can verify your benefits

Cancelof
Primary insurance company
Member ID / Policy #
Group number
Patient relationship to insured

SelfSpouseChildOther
Insured name
Insured phone #
Insured date of birth

MonthDayYear
Date
Insured address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient or Authorized Person's Signature

To the best of my knowledge, the above information is true. I understand that it is my responsibility to inform the practice of any changes in medical status. By signing this form I also acknowledge that I have been given the opportunity to review the Notice of Privacy Practices.
Signature*

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MonthDayYear
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