Patient Information
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PATIENT INFORMATION
Date___________________
Patient’s name ____________________________________________________________________________________
Last
First
Middle
Address __________________________________________________________________________________________
Street
City
Zip
Home Phone______________________ Birthdate_______________ Social Security # ___________________________
If patient is a minor, give parent’s or guardian’s name ______________________________________________________
Whom may we thank for referring you to our office? _______________________________________________________
RESPONSIBLE PARTY INFORMATION
Name ____________________________________________________________________________________________
Last
First
Middle
Residence ________________________________________________________________________________________
Street
City
Zip
Mailing Address ___________________________________________________________________________________
Street
City
Zip
How long at this address?______ Home phone_________________________ Work phone __________________________________
Cell/other phone_________________________ Email address _________________________________________________________
Previous Address (If less than 3 years) _________________________________________________________________
Social Security #_____________________________ Birthdate_________________ Relationship to Patient __________
Employer_____________________________________ Occupation____________________ No. years employed _____
Spouse’s Name_____________________________________________ Relationship to Patient ____________________
Employer_____________________________________ Occupation____________________ No. years employed _____
Social Security # ____________________________ Birthdate __________________ Work Phone __________________
DENTAL INSURANCE INFORMATION
Insured’s Name___________________________________________ Insured’s Social Security #___________________
Insurance Company_________________________ Group No._________________ Local No. _____________________
Insurance Co. Address_________________________________________________ Phone No. ___________________
Do you have dual coverage?
Yes_____
No_____
If yes:
Insured’s Name________________________________________ Insured’s Social Security # ______________________
Insurance Company_________________________ Group No._________________ Local No. _____________________
Insurance Co. Address_________________________________________________ Phone No. ___________________
EMERGENCY INFORMATION
Name of nearest relative not living with you ______________________________________________________________
Complete address __________________________________________________________________________________
Street
City
Zip
Phone ___________________________________________________________________________________________
I understand that, where appropriate, credit bureau reports may be obtained.
Signature (Parent’s signature if minor) ______________________________________________________________________
Updates (date & initial) __________________________________________________________________________________
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Parent category: Medical