Adult New Patient Form

Patient's Name

Date of Birth

Age

Patient Prefers to be called

Home Address

Telephone No.

City

State

Zip Code

Marital Status

Married

Single

Divorced

Occupation

Employer

Business Address

Business Telephone No.

Name of Spouse

Occupation

Employer

Business Address

Business Telephone No.

Name of Person Responsible for Account If Other Than Yourself

Relationship to Patient

Name of Ages or Other Children in Family

Name of Insurance Company

Dentist

Physician

Last Visit to Dentist

Who may we thank for referring you?

DENTAL INSURANCE

Who is responsible for this account?

Relationship to patient

Insurance Co.

Group No.

Subscriber's Name

Birthdate

SS No.

Relationship to patient

Insurance Co.

Group No.

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance Company(ies)

and assign directly to

All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named Insurnace Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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.

Signature of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

PHONE NUMBERS

Home Phone No.

Work Phone No.

Cell Phone No.

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Name

Relationship

Home Phone No.

Work Phone No.

DENTAL HISTORY

Reason for today's visit

Former Dentist

City / State

Date of last dental visit

Date of last dental X-rays

HEALTH HISTORY

Physician's Name

Date of last visit

If yes, Due date

MEDICATIONS

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Phone No.

ALLERGIES

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

Signature of Parent or Guardian

Date

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