Patient Intake Form

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Kalamazoo County Dental Clinic
PATIENT INTAKE FORM
TODAY’S
DATE
/
/
NAME
FIRST
LAST
MIDDLE
SOCIAL
BIRTH DATE
/
/
AGE
SECURITY #
-
-
HOME
ADDRESS
STREET
CITY
STATE
ZIP
HOME
WORK
PHONE
(
)
PHONE
(
)
EMPLOYER
OCCUPATION
PRIMARY
CARE
PHYSICIAN
PHONE
(
)
PREFERRED
PHARMACY
PHONE
(
)
FOR CHILDREN
WHO IS ACCOMPANY THE CHILD TODAY?
NAME
RELATION
LEGAL
CUSTODY?
YES
NO
MOTHERS INFORMATION:
NAME
BIRTH DATE
/
/
WORK
PHONE
(
)
PHONE
(
)
FATHERS INFORMATION:
NAME
BIRTH DATE
/
/
WORK
PHONE
(
)
PHONE
(
)
The Kalamazoo County Health & Community Services programs are open to all without regard to race, color, national origin, sex, or disability.
J:\Dental\Forms\Record Forms\Patient Information Form.docx (tlp 8/19/09)

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