Patient Information

Patient's Full Name

Today's Date

Parent/Legal Guardian/Spouse's Full Name

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Whom may we thank for referring you?

Patient Information

Sex

Male Female

Email Address

Date of Birth

Primary Phone #

Type of Phone

Home Mobile Work

Add Additional Phone Number

Address

City

State

ZIP

Employment/School Information

Employer/School

Employer/School Phone #

Employer/School Address

City

State

ZIP

Spouse/Guardian Information

If you are the Parent/Guardian or Spouse of the patient, please complete the following information.

Email address

Are you currently a patient in our office?

Yes No

Check here if your address is the same as the Patient's

Otherwise, please add your address below

Add other address

Emergency Contact Information

Add Emergency Contact Person

Responsible Party

Who is the "Responsible Party" for this account?

Patient Spouse Parent/Legal Guardian Other

If the responsible party is someone OTHER than the Patient, Spouse or Parent/Legal Guardian listed above, please add your information below.

Add Responsible Party Information

Responsible Party's Bank Name

Insurance Information

Who is the "Insured Party"?

Patient Spouse Parent/Legal Guardian Other None

If the "Insured Party/Individual" is someone OTHER than the Spouse or Parent/Legal Guardian, then please add your information below.

Add "Responsible Party" Information

Please provide your insurance information below:

Add Insurance Information

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

Your information will be encrypted.

Patient Information

Patient Information

Employment/School Information

Spouse/Guardian Information

Emergency Contact Information

Responsible Party

Insurance Information

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

Kewaskum Family Dentistry