New Patient Forms
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1
2WELCOME to IDEAL DENTISTRY!
To assist us in serving you, please complete the following confidential forms.
PATIENT INFORMATION
Last Name
First Name
M.I.
Birthdate
Soc. Sec.#
Sex
M
F
Street Address
City
State
Zip
Employer
Occupation
Marital Status
Email
Home Phone
Cell Phone
Work Phone
NOTIFY IN CASE OF EMERGENCY
Phone
PRIMARY DENTAL INSURANCE
Responsible Party for Account
Last Name
First Name
M.I.
Relation to Patient
Birthdate
Soc. Sec. #
Address
)
Phone
(If different from Patient
City
State
Zip
Occupation
Responsible Party's Employer
Business Address
Insurance Company
Business Phone
Group #
Subscriber #
Contract #
Name of other dependents on this plan
SECONDARY DENTAL INSURANCE
Relation to Patient
Birthdate
Subscriber's Name
Address
)
(If different from Patient
City
State
Zip
Business Phone
Subscriber's Employer
Soc. Sec. #
Insurance Company
Group #
Subscriber #
Contract #
Name of other dependents on this plan
HOW DID YOU FIND OUT ABOUT OUR DENTAL PRACTICE
Referral
(By Whom)
Daily News Sun
Google Ad
Google Search
Yelp
Yahoo
Bing
Facebook
Pinterest
Other
AUTHORIZATION
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge.
I understand that this information will be used by the dentist to help determine appropriate and healthful
dental treatment. If there is any change in my medical status, I will inform the dentist. I authorize my insurance
company to pay Ideal Dentistry all insurance benefits otherwise payable to me for services rendered.
I authorize the use of this signature on all insurance submissions. I authorize Ideal Dentistry to release all
information necessary to secure the payment of benefits. I understand that I am financially responsible for all
charges whether or not paid by insurance. Payment is due in full at time of treatment.
Signature________________________________________________________Date____________________
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