To assist us in serving you, please complete the following form. The information provided is important to your professional dental health. If there have been any changes in your health, please let us know. If you have any questions, please feel free to ask us, we will be happy to help you complete it.
Patients are required to pay in full at the time of service. Cash, Check, Visa, MasterCard, Discover, American Express or CareCredit are accepted forms of payment.
Patient Information & Medical History
- Location
- Today's Date
- Sex
Male Female
- Legal Name
- Age
- Preferred Name
- Date of Birth
- SSN#
- Address
- City
- State
- Zip
- Billing Address (if different)
- City
- State
- Zip
Divorced Married Single Widowed
- Home Phone
- Cell Phone
- Spouse/Partner's Name
- Spouse/Partner's phone
- Emergency contact name & phone
- Appointment Confirmation method (Please check one)
Phone call Text message Email
- Do you have Dental Insurance
Yes No
- Primary Dental Insurance
- Insurance Co. Name
- Group #
- Subscriber ID
- Subscriber's Name
- Relationship
- Employer
- Date of Birth
- SSN#
- Secondary Dental Insurance (if applicable)
- Insurance Co. Name
- Group #
- Subscriber ID
- Subscriber's Name
- Relationship
- Employer
- Date of Birth
- SSN#
- How would you like to receive your bills? (Please check one)
Email Mail
- Pharmacy name
- Address
- Phone
- Physician & number
- Cardiologist & number