Patient Information Form

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Patient Information
                                        Today’s Date________________ 
NAME:______________________________________________________________________________________________________ 
 
 
(LAST) 
 
 
 
 
 
(FIRST) 
 
 
 
(MIDDLE)
ADDRESS:_________________________________________________CITY:____________________________ZIP:________________ 
HOME#:_________________________PAGER/CELL#:______________________WORK#:__________________________EXT:______ 
EMAIL ADDRESS:____________________________ 
PREVIOUS ADDRESS IF LESS THAN 3 YEARS:_________________________________________________________________________ 
SOCIAL SECURITY # ________ ‐ _____ ‐ _________  GENDER:    M      F      DATE OF BIRTH:_____________________AGE:___________ 
MARTIAL STATUS: 
MARRIED 
               SINGLE   
DIVORCED 
EMPLOYER:__________________________________________________________NUMBER OF YEARS EMPLOYED:_______________ 
SPOUSE OR PARENT NAME: __________________________________________________WORK PHONE:_______________________ 
SOCIAL SECURITY NUMBER # ________ ‐ _____ ‐ _________   
DATE OF BIRTH:_______________________AGE:__________ 
EMPLOYER:__________________________________________________________NUMBER OF YEARS EMPLOYED:_______________ 
DENTAL INSURANCE INFORMATION 
INSURED’S NAME:____________________________________________________SOCIAL SECURITY # ________ ‐ _____ ‐ _________ 
ADDRESS:______________________________________________CITY:_______________________________ZIP:________________ 
EMPLOYER:_____________________________________GROUP #____________________DATE OF BIRTH:_____________________ 
INSURANCE COMPANY/ADDRESS:________________________________________________________________________________ 
EMERGENCY INFORMATION 
CLOSEST FRIEND/RELATIVE NOT LIVING WITH YOU:__________________________________________________________________ 
PHONE:________________________ADDRESS:_____________________________________________________________________ 
RELATIONSHIP TO PATIENT:_____________________________________________________________________________________ 
METHOD OF PAYMENT 
WHICH OF THE FOLLOWING METHODS OF PAYMENT WILL YOU BE USING? (FEE MUST BE PAID IN FULL AT THE COMPLETION OF 
TREATMENT.)  CASH:_______, CHECK:___________, MC:__________, VISA:___________ 
ALL INFORMATION WRITTEN IS TRUE AND COMPLETE. IF THE ACCOUNT IS PLACED WITH A COLLECTION AGENCY, ALL REASONABLE 
COSTS AND/OR LEGAL FEES SHALL BE THE RESPONSIBILITY OF THE UNDERSIGNED.  
SIGNATURE:__________________________________________________________________________________________________ 
IF DENTAL INSURANCE APPLIES:   ALTHOUGH THIS OFFICE FILES INSURANCE CLAIMS AS A SERVICE TO THE PATIENT, THE INSURANCE 
CONTRACT IS BETWEEN THE PATIENT AND THE INSURANCE COMPANY. AS WE HAVE NO CONTROL OVER THE INSURANCE 
COMPANY’S METHOD OF PAYMENT OR AMOUNT OF PAYMENT, ANY DIFFERENCE OF PAYMENT IS ENTIRELY THE RESPONSIBILITY OF 
THE PATIENT/RESPONSIBLE PARTY. 
INITIALS:__________________ 
FUTURE UPDATES (DATE & INITIAL)_______________________       _________________________       ________________________ 
ALL INFORMATION PROVIDED IS CONFIDENTIAL (FOR RECORD AND EVALUATION) 
 

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