New Patient Information Form

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us we will be happy to help.

PATIENT INFORMATION (CONFIDENTIAL)

Date

Patient's Name

Birthdate

SS # / SIN

Home Phone

Cell Phone

Address

City

State / Prov

Zip / P.C.

Spouse or Parent/Guardians Name

Whom may we thank for referring you?

Person to contact in case of emergency

Phone

RESPONSIBLE PARTY

Name of Person

Relationship to Patient

Address

Home Phone

Cell Phone

Driver's License #

Birthdate

Employer

Work Phone

SS#/SIN

Is this person currently a patient in our office?

Yes No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Cash

Personal Check

Credit Card

INSURANCE INFORMATION

Name of Insured

Relationship to Patient

Birthdate

SS #/SIN

Name of Employer

Union or Local #

Insurance Company

Group #

Policy ID #

Ins. Co. Address

City

State / Prov

Zip / P.C.

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.

Patient's Signature

Date

Patient Dental & Medical Health History Information

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Authorization and Release

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Your information will be encrypted.