New Patient Form

Patient's Name

Middle

Last Name

Date of Birth

Address

City

State

Zip Code

Cell Phone No.

Home Phone No.

Preferred Contact No.

Email address

Employment Status

Full time Part time Unemployment Retired Other

Name of Parent/Guardian

Phone No.

Address (If different)

Emergency Contact

Relationship

Phone No.

How did you hear about us?

Referring Person Name

Dental Insurance Information ( Please present insurance card at time of check-in)

Primary Dental Insurance Name

Employer

Name Of Insured

Date of Birth

Insurance Phone No.

ID No.

Group No.

Pharmacy Name/Location

Phone No.

Primary Care Dr. (PCP)

Phone No.

Financial Policy: It is customary to pay for services at the time they are rendered unless other arrangements have been made. To assist you with this, we accept all major credit cards. On major services( crowns, dentures, etc.) 50% of the fee is due at the first treatment, and the remaining balance is due at the time of completion. If you have dental insurance, please have all necessary forms completed and your insurance card available. Out-of-network provider costs may be more than in-network provider costs. We may accept the assignment of benefits, however, you will be responsible for any amount not paid by the insurance company.

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 Name

Date

Patient/Guardian Signature

Relationship

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