Adult Pre-Clinical History
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4Adult Pre-Clinical History
We are happy to have you
Today’s date: ____________
join our great family of
ABOUT YOU
patients and friends.
Name: ____________________________________________________
Female
Male
Nickname: ______________________________________________________________________
The benefits of a healthy,
Address: ________________________________________________________________________
beautiful smile are
immeasurable, and our
City: __________________________________________ State:________ Zip: ______________
goal is to allow you to
Home phone: ___________________________ Bus. phone: _____________________________
obtain the healthy teeth
Cell phone: ______________________________________________________________________
and attractive smile you
Birth date: _____/_____/_____
Marital status:
Single
Married
Widowed
want and deserve.
E-mail address: __________________________________________________________________
Name of spouse: ________________________________________________________________
Please complete this
Names of children: ______________________________________________________________
form so that we can
provide the best care
How do you enjoy spending your free time? __________________________________________
possible for you.
Who can we thank for referring you? ________________________________________________
EMERGENCY INFORMATION
Thank you!
Person to contact: ______________________________________________________________
Relationship: ___________________________________ Phone: _________________________
I give permission for Boger Dental to share my medical and account information with:
________________________________________________________________________________
DENTAL INSURANCE INFORMATION
Name of Primary Insurance Company: _____________________________________________
Address: _______________________________________________________________________
Phone: ________________________________________________________________________
Name of policy holder: __________________________________________________________
Relationship to policy holder:
Self
Spouse
Child
Other ____________________
Policy holder’s ID/social security #: __________________________
Group #: ____________
Policy holder’s birth date: _____/_____/_____
Policy holder’s employer: ________________________________________________________
Name of Secondary Insurance Company: _____________________________________________
Address: _______________________________________________________________________
Phone: ________________________________________________________________________
Name of policy holder: __________________________________________________________
Relationship to policy holder:
Self
Spouse
Child
Other ____________________
Policy holder’s ID/social security #: __________________________
Group #: ____________
Policy holder’s birth date: _____/_____/_____
Policy holder’s employer: ________________________________________________________
2720 Annapolis Circle N., Suite A, Plymouth, MN 55441
763-546-7707 phone
763-546-7713 fax
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Parent category: Medical