Patient Information Form - Stony Creek Dentistry

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Welcome to Stony Creek Dentistry!
To help us better serve you, please fill out this form completely. If you have
any questions or need assistance, please ask us and we will help.
Patient Information:
Name: _______________________________________________
Date: _________________________
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Male
Female
Are you:
Married
Single
Child
Spouse’s Name: __________________
SS#: ______________________ Birth Date __________________
Home Phone: ___________________
Address: ________________________
___________________
Cell Phone: _____________________
___
______________________________________________
Email: ________________________
Contact Person
:__________________________
Phone Number: __________________
(who does not live with you)
Responsible Party:
if child or another adult
Name of Person Responsible for Account: _______________________
Relationship to Patient: _____________
SS#: ______________________ Birth Date __________________
Home Phone: ____________________
Address: ________________________
___________________
Cell Phone: _____________________
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______________________________________________
Email: ________________________
Insurance Information:
please provide us with your dental insurance card so we may make a copy
Name of Primary Insured: __________________________________
Relationship to Patient: _____________
SS#: ______________________ Insured Birth Date ____________
Home Phone: ____________________
Employer: _____________________________________________
Work Phone: ____________________
Employer Address: _______________________________________
Insurance Company: ______________________Group # __________
Policy #: _______________________
Insurance Company’s Phone Number: __________________________
Deductible used this year: ___________
If you have Secondary Dental Insurance please complete the following section.
Name of Secondary Insurance: ______________________________
Subscriber Name: ________________
Subscriber’s SS#: _______________________________________
Subscriber’s Birth Date: ____________
Employer: ______________________________ Group _________
Policy #: ______________________
Referral Information:
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How did you hear about us?
Internet
Mail
Yellow Pages
Drive By
Insurance Company
Radio
Referral
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Who referred you to our dental practice?
Patient
Doctor/Dentist
Spouse
Friend
Family Member
Name of person or office referring you to our practice: ________________________________________________
Please complete and sign the other side of this form >>

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