New Patient Information Form

ADVERTISEMENT

P
F
EW
ATIE T
ORM
A
Y
BOUT
OU
oday’s Date:
Email Address:
Last Name:
First Name:
I prefer to be called:
Marital Status:
Single
Married
Divorced
Widowed
Seperated
Birthdate:
Age:
Soc. Sec. #:
Gender:
Female
Male
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Ext.
Driver’s License #:
hom may we thank for referring you?
Other family members seen by us:
In Case of Emergency, Whom Should We Contact:
Name:
Relation:
Work Phone:
Cell Phone:
Home Phone:
Person Responsible for Account:
Name:
Relation:
Phone:
Address:
I
I
NSURANCE
NFORMATION
Primary Insurance
Insurance Co. Name:
Phone:
Group:
Insurance Co. Address:
City:
State:
Zip:
Insured’s Name:
Insured’s Soc. Sec. #:
Insured’s Birthdate:
Relation:
Employer’s Name & Address:
Secondary Insurance: (if applicable)
Insurance Co. Name:
Phone:
Group:
Insurance Co. Address:
City:
State:
Zip:
Insured’s Name:
Insured’s Soc. Sec. #:
Insured’s Birthdate:
Relation:
Employer’s Name & Address:
he above information is true and correct to the best of my knowledge. I authorize and give consent to perform dental service agreed between the dentist(s) and
myself and/or to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I understand that, regardless of insurance
coverage, I am responsible for payment of services rendered and that a finance charge of 23% APR or 1.92% per month will be applied to accounts pas due 90 days
or more.
Patient Signature:
Date:

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go