New Patient Information

Date

SS / HIC / Patient ID No.

Patient's Name

Address

City

State

Zip code

Date of Birth

Age

Single Married Widowed Separated Minor Divorced

If partnered, For how many years?

Patient Employer / School

Occupation

Employer / School Address

Employer's School Phone No.

Spouse's Name

Date of Birth

SS No.

Spouse's Employer

Whom we may 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 Companies and assign directly to

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 dentist may use my health card information and my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining information benefits or the benefit payable for related service. This consent will and when my current treatment plan is completed or one year from the date signed below

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

Relation to Patient

Date

PHONE NUMBERS

Phone No.

Work Phone No.

Ext (Alt Number)

Spouse Work

Best time and place to reach you

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

Name

Relationship

Phone No.

Work Phone No.

DENTAL HISTORY

Reason for today's visit

Former Dentist

State

City

Date of Last Dental Visit

Date of Last Dental X-rays

How often do you floss?

HEALTH HISTORY

Physician Name

Date of last visit

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

If Other, please specify.

Updates (to be filled in at future appointments)

For what conditions?

if so what?

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 Signature

Date

Your information will be encrypted.