Insurance Worksheet

Please correct the errors described below.

APPT DATE:

APPT TIME:

ACCT #:

HEAD OF HOUSEHOLD:

DATE OF BIRTH:

HEAD OF HOUSEHOLD'S ADDRESS:

CITY:

ZIP:

HEAD OF HOUSEHOLD SSN:

PHONE:

EMAIL ADDRESS:

REFERRED BY:

SUBSCRIBER NAME:

DATE OF BIRTH:

SUBSCRIBER EMPLOYMENT:

WORK NUMBER:

SUBSCRIBER INSURANCE:

INS PHONE #:

SUBCRIBER SSN:

INS BILLING ADD:

GROUP NUMBER:

MEMBER ID NUMBER:

WHEN AND WHERE WAS YOUR LAST CLEANING AND EXAM?

HAVE YOU BEEN TO THE DENTIST THIS YEAR?

YES NO

IF YES, WHAT WORK WAS COMPLETED?

HAVE YOU EVER HAD A PANORAMIC X-RAY TAKEN?

YES NO

IF YES WHEN?

ARE YOU HAVING PAIN?

YES NO

IF YES: WHERE?

UR LR UL LL

IS IT WAKING YOU UP AT NIGHT?

YES NO

IS IT BOTHERING YOU WHEN BRUSHING

YES NO

IS IT BOTHERING YOU WHEN YOU EAT?

YES NO

IS IT HOT/COLD SENSITIVE?

YES NO

DO YOU HAVE ANY CONCERNS?

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