Patient Registration and Health History Form

Please complete the following confidential patient Information so that we may make your visit pleasant and comfortable.

How Did You Hear About Our Office?

Family/Friend

Mailer

Referral Brochure

Building Sign Drive-By

Website / Web Search Engine

The Talking Ph one Book

Other

If Family/Friend, Specify Name

If Referral If Check, From who?

If Other, Please Explain

Patient's Name

Nickname

Date of Birth

Age

Street Address

City

State

Zip Code

Occupation

Emergency Contact

Employer

Emergency Contact #

Employer Location

Driver's License No.

Phone Number

Work Phone

Cell Phone

Social Security No.

Email Address

Spouse's Name (or parent's if minor)

Spouse's Employer (or parent's if minor)

Primary Dental Insurance

Add new row

Secondary Dental Insurance

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Insurance Authorization Statement (Please sign and date)

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs incurred during dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history is correct to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name / Signature

Date

If Patient is Under 18 Years of Age

Responsible Party

Relationship to Patient

Street Address

City

State

Zip Code

Phone Number

Number

Your information will be encrypted.