General Information Form
Patients Names:
Name of Child 1
Name of Child 2
Name of Child 3
Name of Child 4
Referred by:
Emergency Contact (Please list contact other than parent/guardian)
(Name, relationship to patient, home phone)
Parent/Guardian Information
Mother
Birthdate
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Employer
Occupation
Work Phone
Format: (000) 000-0000.
E-mail address
example@example.com
Father
Birth Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Employer
Occupation
Work Phone
Format: (000) 000-0000.
E-mail address
example@example.com
Patient Insurance Information
Primary Insurance (Company name, please provide copy of card)
Subscriber (Legal name)
Birth Date
-
Month
-
Day
Year
Date
Relationship
ID #
Group #
Effective date
Secondary Insurance (Company name, please provide copy of card)
Subscriber (Legal name)
Birth Date
-
Month
-
Day
Year
Date
Relationship
ID #
Group #
Effective date
I hereby authorize Hi 5 Dental to provide dental services to the above named patient (s) and to use and release medical and dental information as required for treatment, payment, and health care operations. I also assign Hi 5 Dental all payments to which I am entitled for dental procedures. I understand that I am financially responsible for all charges whether covered by insurance or not. I have received a copy of the current Privacy Notice and Financial Policy.
Please check if you DO NOT want to be contacted by:
Post card (US mail)
Phone call
Email
Text message
Parent/Guardian Signature
Relationship to patient
Date
-
Month
-
Day
Year
Date
14671 SW Millikan Way
Beaverton, OR 97006
Phone: 503-644-4749
Fax: 503-747-6192
3075 SE Century Blvd Suite #109
Hillsboro, OR 97123
Phone: 503-642-1535
Fax: 503-649-2286
2375 SW Cedar Hills Blvd
Portland, OR 97225
Phone: 971-713-3899
Fax: 503-747-6192
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