New Patient Information

Is this for an adult or child?

Adult Child

Patient First Name

Patient Middle Name

Patient Last Name

Patient Preferred Name

Home Phone

Cell Phone

Work Phone

Home Phone

Cell Phone

Social Security Number

Sex

Male Female Other

Explain

Sex

Male Female Other

Explain

Age

Date of Birth

Email address

Age

Date of Birth

Email address

Address

City

State

Zip

Address

Address 2

City

State

Zip

Patient's Employer

Current Job Title

Number of years at this employer

Mother's Employer

Mother's Current Job Title

Mother's number of years at this employer

Father's Employer

Father's Current Job Title

Father's number of years at this employer

Who is responsible for this account

Who may we thank for this referral?

Other family members who are patients here?

Spouse First Name

Spouse Last Name

Spouse Primary Phone

Spouse Email

Spouse Date of Birth

Mother's First Name

Mother's Last Name

Mother's Primary Phone

Mother's Email

Mother's Date of Birth

Father's First Name

Father's Last Name

Father's Primary Phone

Father's Email

Father's Date of Birth

Mother's Address

Address 2

City

State

Zip

Father's Address

Address 2

City

State

Zip

Do you have Insurance?

Yes No

First Name of Primary Insured

Last Name of Primary Insured

Insurance ID #

Insurance Company Name

Group Name

Group Number

Birthdate of Primary Insured

Primary Insured Relationship to Patient

Upload Insurance (Front & Back)

Add file

Please upload a file

Do you have Secondary Insurance?

Yes No

First Name of Secondary Insured

Last Name of Secondary Insured

Insurance ID #

Insurance Company Name

Group Name

Group Number

Birthdate of Secondary Insured

Secondary Insured Relationship to Patient

Upload Insurance (Front & Back)

Add file

Please upload a file

Insurance Card Image Upload

Add file

Please upload a file

Parent's First Name

Parent's Last Name

_______________________________
Patient/Client Signature (to be signed at time of first visit)

__________________
Date

_______________________________
Parent's Signature (to be signed at time of first visit)

___________________
Date

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New Patient Information

Penfield Family Dentistry