New Patient Information Form

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New Patient Information
We are committed to excellence in dentistry and appreciate you taking the time to complete this
confidential questionnaire. The better we communicate, the better we can care for you. If you have any
questions or need assistance, please ask us - we will be happy to help.
Whom may we thank for referring you?___________________________________________
ABOUT YOU
Name: _______________________________I prefer to be called:_______________ [ ] Male [ ] Female
Birth date: ___/___/___ Age: _____ Care Card ___________________ DL/ID____________________
D M
YR
Home Address: _____________________________________________
City_____________________________________________Prov____Postal Code_______________
HomePhone:(____)____________Work: (____) __________ ext. ___ Cell: (____) _______________
E-mail Address: ________________________________________________
Check preferred contact: Telephone home___cell ___work___ Text_________or Email __________
Employer: _______________________________ Occupation: _____________________
Employer’s Address:_____________________City______________Prov____ Postal Code___________
PERSON RESPONSIBLE FOR ACCOUNT
[ ] Same as above
Name:___________________________________ Birth date:___/___/___ Relation: ________________
D M
YR
BillingAddress:_________________________City______________Prov____Postal Code___________
HomePhone:(____)________________Work:(____)__________________Cell(
)________________
Employer’s Address:_____________________City______________Prov____ Postal Code___________
DENTAL INSURANCE INFORMATION
Primary Insurance
InsuranceCo Name:____________________Phone:(____)________Group/Policy#:_________________
Insured’sName:_________________________Insured’sBirthdate:___/___/___Relation:______________
D M YR
ID/Certificate or Employee#___________________Insured’s Employer:___________________________
Secondary Insurance
Insurance Co.Name:___________________Phone:(____)_________Group/Policy#_________________
Insured’s Name: __________________Insured’sBirth date: ___/___/___ Relation: __________________
D
M
YR
ID/Certificate or Employee#_____________________Insured’s Employer: _______________________

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