Patient Information (Confidential)

Full Name

Today's Date

Birth Date

Social Security #

Driver’s License #

Gender

Male Female

Status

Minor Single Married Separated Divorced Widowed

Address

City, State and Zip

Home Phone

Work

Cell Phone

E-mail

If you are a College Student, name of School

School Address

Are you a full-time or part-time (Pick one)

Full Time Part Time

Emergency Contact

Phone Number

Date of your last Dental visit

Date of last Dental x-rays

Whom may we thank for referring you?

Responsible Party (if other than patient)

Person responsible for this account

Relationship to Patient

Phone Number

Address if different from above

City, State and Zip

Is this person currently a patient in our practice?

Yes No

Dental Insurance Information

Name of Insured/Subscriber

Relationship to Patient

Social Security #

Birth Date of Insured

Name of Employer

Union or Local Number

Insurance Company

Phone Number

ID Number

Group Number

Insurance Company Address

City, State and Zip

Is patient covered by another insurance plan? (If yes, be sure to tell our front desk)

Yes No

Reason for today’s visit

Date of last Dental x-rays

Date of last Dental visit

Name of former Dentist

How often do you brush?

How often do you floss?