New Patient Information

Patient Information

First Name

Middle Initial

Last Name

Social Security Number

Birthdate

Age

Sex

Home Phone

Address

City

State

Zip Code

Name of School

City

State

Parent/Responsible Party

Please provide copy of driver license.

Add file

Please upload a file

Person Responsible for Account

Relationship to Patient

Address

City

State

Zip Code

Home Phone

Cell Phone

Driver's License

Birthdate

Social Security Number

Employer

Work Phone

Extension

Home Email

Work Email

Whom may we thank for referring you?

Emergency Contact

Phone

Cell

Dental Insurance Information

Provide copy of insurance card and driver license.

Add file

Please upload a file

Add secondary insurance

Payment for services is due in full at the time of treatment unless prior arrangements have been made.

If this account should go to collections, you will be responsible for all collection fees and any attorney fees.

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

Signature

Date

Relationship to Child

Your information will be encrypted.