Welcome
Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help.
Patient #
SS#/SIN
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Information
(CONFIDENTIAL)
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Zip / P.C.
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status
Minor
Single
Married
Divorced
Widowed
Separated
If Student
School/College Name
City
State/Province
Student Status
Full Time
Part Time
Patient / Guardian Employment
Patient or Parent/Guardian's Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse / Guardian Information
Spouse or Parent/Guardian's Name
Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Information
Whom may we thank for referring you?
Emergency Contact
Person to contact in case of emergency
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party
Name of Person Responsible for this Account
Relationship to Patient
Address
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Driver's License #
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Financial Institution
Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
SS#/SIN
Is this person currently a patient in our office?
Yes
No
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
Cash
Personal Check
Credit Card
VISA
MasterCard
I wish to discuss the office's payment policy
Insurance Information
Name of Insured
Relationship to Patient
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SS#/SIN
Date Employed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Employer
Union or Local #
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
Group #
Policy/ID #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How much is your deductible?
How much have you used?
Max. annual benefit
Do You Have Any Additional Insurance?
Yes
No
Name of Insured
Relationship to Patient
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SS#/SIN
Date Employed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Employer
Union or Local #
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
Group #
Policy/ID #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How much is your deductible?
How much have you used?
Max. annual benefit
Submit
Should be Empty: