Welcome to our Practice

PATIENT INFORMATION

Title:

Mr. Mrs. Ms. Dr.

First Name:

MI:

Last Name:

Nickname:

Sex:

Male Female

Birth Date:

Email:

Street:

City:

State:

Zip:

Home #.

Cell #:

Status:

Married Divorced Separated Widow Single

Employer:

Bus. Tel #:

Spouse:

Work #:

Cell #:

Person to call in case of emergency:

Tel #:

College Student:

F/T P/T

Name of School:

City/ST:

Whom may we thank for referring you?

Doctor Friend Newspaper Website Insurance Plan Other

If Doctor, please provide Name:

If Friend, please provide Name:

If Other, please specify:

Responsible Party

Who will be responsible for your account?

Self Spouse Father Mother Other

If Other, please specify:

(If self, skip to next section)

Name:

Birth Date:

Age:

Tel. #:

Employer:

Bus Tel #:

INSURANCE INFORMATION

Primary Dental Insurance Company

Name of Insured:

Relation:

Sex:

M F

Birth Date:

SS #:

Employer:

Local/Union:

Ins. Co.:

ID#:

Group #:

Group Name:

Address:

City:

State:

Zip:

Tel #:

Medical Dr.:

Secondary Dental Insurance Company

Name of Insured:

Relation:

Sex:

M F

Birth Date:

SS #:

Employer:

Local/Union:

Ins. Co.:

ID#:

Group #:

Group Name:

Address:

City:

State:

Zip:

Tel #:

Previous Dentist:

Permission for Dental Examination and Treatment

I do hereby authorize and consent to any x-rays, examination, anesthetic, or dental treatment rendered under the general, direct, or indirect supervision of Dr. Siao and/or staff members they may deem necessary. This authorization will remain in effect until cancelled in writing by me.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Parent/Guardian Signature:

Date:

Your information will be encrypted.