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Harmony Family Dental
Harmony Family Dental
10103 N. DIVISION SUITE 201
SPOKANE, WA 99218
509-467-1562
New Patient Form
Please fill out all the information to the best of your knowledge. All answers will be
Date:
Patient #:
kept confidential. If you have any questions, please ask us, and we'll be happy to
/
/
assist you.
01
01
2017
Patient Information
02
02
2018
Title:
First Name:
Middle Name:
Last Name:
I prefer to be called:
03
03
2019
04
04
2020
Mr.
Sex:
Age:
Date of Birth (mm/dd/yyyy):
Marital Status:
Social Security #:
Driver's Licence State & #:
05
05
2021
Ms.
/
/
-
-
06
06
2022
Mrs.
M
01
01
2027
Minor
AL
07
07
2023
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
Dr.
F
02
02
2026
Single
AR
08
08
2024
-
-
-
-
-
-
03
03
2025
Married
AZ
09
09
2025
Home Address:
City:
State: ZIP Code:
04
04
2024
Long-Term Partner
CA
10
10
2026
05
05
2023
Divorced
CO
11
11
2027
AL
06
06
2022
Widowed
CT
12
12
Employment:
Employer's Name:
Employer's Phone:
Occupation:
AR
07
07
2021
Separated
DC
-
-
13
AZ
08
08
2020
DE
14
None
Employer's Address:
City:
State: ZIP Code:
CA
09
09
2019
FL
15
Full-Time
CO
10
10
2018
GA
16
Part-Time
AL
CT
11
11
2017
HI
Student Status:
School Name (if a full-time student):
Grade:
17
Retired
AR
DC
12
12
2016
IA
18
AZ
DE
Not a Student
13
2015
ID
19
Best places and times to contact you:
Send appointment reminders via:
CA
FL
Full-Time
14
2014
IL
20
Text Message
Email
Mail
CO
GA
Part-Time
15
2013
IN
21
CT
HI
Please tell us where you heard about us (check all that apply):
16
2012
KS
22
DC
IA
Friend or Relative (name):
Newspaper Ad
Radio Ad
TV Ad
17
2011
KY
23
DE
Ad in Mail
Saw our Office
Insurance Company
Our Website
ID
18
2010
LA
24
FL
Search Engine (Google, etc.)
Other Website:
IL
19
2009
MA
25
GA
Other:
IN
20
2008
MD
26
HI
KS
21
2007
ME
27
Was our website a factor in your decision to visit our practice?
Yes
No
IA
KY
22
2006
MI
28
Name of Spouse (or Parent, if a minor): Spouse/Parent's Employer: Spouse/Parent Work Phone:
Spouse/Parent Cell Phone:
ID
LA
23
2005
MN
29
-
-
-
-
IL
MA
24
2004
MO
30
IN
Other family members treated by us:
Additional Comments:
MD
25
2003
MS
31
KS
ME
26
2002
MT
KY
MI
27
2001
NC
LA
MN
28
2000
ND
MA
MO
29
1999
NE
MD
MS
30
1998
NH
ME
MT
31
1997
NJ
MI
NC
1996
NM
MN
ND
1995
NV
MO
NE
1994
NY
MS
NH
1993
OH
MT
NJ
1992
OK
NC
NM
1991
OR
ND
NV
1990
PA
Page 1/16
NE
NY
1989
RI
NH

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