Patient Personal Information printable pdf download

Welcome

PATIENT PERSONAL INFORMATION

Name: ______________________________________________________ M[ ] F[ ] Age: __________________Birthday: ____________

Address: ____________________________________________ City: ________________________Zip: ___________________________

Home Phone: _________________________ Cell Phone: _____________________

Spouse Name If Applicable: _________________

PATIENT/RESPONSIBLE PARTY INFORMATION

Responsible Party (if not Patient):____________________________________________________________________

RELATIONSHIP TO PATIENT [ ] parent

[ ] other ______________________________________________________

Responsible Party Home Phone: ______________________ cell: ________________________ work: ____________________________

Street Address: _________________________________ City: ______________________ State: _______________ Zip: ______________

Employers Name: ___________________________Address: ___________________________ Phone No. _________________________

Please Present Insurance Card

PATIENT INSURANCE INFORMATION

PRIMARY Insurance Company Name:____________________________________ Insurance Phone:_____________________________

Name of Insured: ______________________________ Insured SS#: ________-_______-__________ or ID#________________

Birthday: ____________________ Employment of insured: ________________________

SECONDARY Insurance Company Name:_____________________________________________________________________________

Name of Insured: ______________________________ Insured SS#: ________-________-___________ or ID#______________

Birthday: __________________

Employment of insured: ________________________

EMERGENCY CONTACT

Who Should We Notify Locally, Other Than Spouse, In Case Of Emergency? _________________________________________________

Relationship: _________________ Phone: _________________

Have any of your family members been seen in this office?

Yes [ ] No [ ]

Name_______________________________

Have you previously had braces [ ] yes [ ] no Whom may we thank for referring you? _________________

Reason For Today’s Visit

: ____________________________________________________________________________________

Do you want e-mail reminders of up coming appointments? E-mail address

___________________________________

I Understand and Agree that (regardless of my insurance status), I am ultimately responsible for the balance of my

account. I certify that this information is true and correct to the best of my knowledge.

____________________________________________date______________________ PARENT/GUARDIAN SIGNATURE

Patient Personal Information