New Patient Form

Are you a new patient? Save time on paperwork by filling out the forms below prior to your appointment. If you have any questions, please feel free to give us a call. We can’t wait to meet you!

PATIENT INFORMATION

DENTAL INSURANCE

PHONE NUMBERS

DENTAL HISTORY

HEALTH HISTORY

UPDATES (To be filled in at future appointments)

Date

SS/HIC/Patient ID #

Patent Name

Address

Email address(required)

City

State

Zip

Sex(required)

Age

Birthdate

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse’s Name

Spouse's Birthdate

SS#

Spouse’s Employer

Whom may we thank for referring you?

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional Insurance?

Yes

Subscriber’s Name

Birthdate

SS#

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

I certify that I and/or my dependent(s) have insurance coverage with

And assign directly to Dr.

All insurance benefits, it any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges whether or not paid by insurance I authorize the use of my signature on all insurance submissions.

The above named dentist may use my health care information and may disclose such information to the above named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services This consent will end when my current treatment plan is completed or one year form the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or personal Representative

Date

Relationship to Patient

Home

Work

Ext

Cell Phone

Spouse’s Work

Spouse’s Work Best time and place to reach you

IN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household.)

Name

Relationship

Home Phone

Work Phone

Has there been any change in your health since your last dental appointment?

Yes

For what conditions?

Any you taking any new medications?

If so, what?

Patient’s Signature

Date

Doctor’s Signature

Date

This field should be left blank

New Patient Form

MEDICATIONS

ALLERGIES