PBC Perio Patient Information Form

Patient Information
Date*

MonthDayYear
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Social Security No.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Check One:*

MinorSingleMarriedDivorcedWidowedSeparated
Patient's or Parent's Employer
Work Phone

Area CodePhone Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse or Parent's Name
Employer
Work Phone

Area CodePhone Number
Whom May We Thank for Referring You?
In Case of Emergency Contact (Name of Person)*
If you would like us to call 911, please type "Emergency" in box
Please type phone number of contact or 911 in box*
Responsible Party
Name of Person Responsible for this Account
Relationship to Patient
Email
example@example.com
Birthdate

MonthDayYear
Date
Social Security No.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Currently a Patient in our Office?

YesNo
Home Phone

Area CodePhone Number
Employer
Work Phone

Area CodePhone Number
Insurance Information
1) Primary Insured's Name
Relation to Patient
Date of Birth

MonthDayYear
Social Security No.
Date Employed

MonthDayYear
Date
Employer
Work Phone

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group Number
Union or Local Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Insurance Information
2) Secondary Insured's Name
Relation to Patient
Date of Birth

MonthDayYear
Social Security No.
Date Employed

MonthDayYear
Date
Employer
Work Phone

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group Number
Union or Local Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby state that, to the best of my knowledge, the above information is true and accurate, complete to my satisfaction, and that I will not hold the dentist or the staff responsible for any errors or omissions in the completion of this form.
Name*

First NameLast Name
Signature of Patient / Legal Guardian*

Clear
Date*

MonthDayYear
I authorize the release of any information related to my health care or to my claims. I understand that I am financially responsible for the costs related to treatment. I authorize payment of my benefits, otherwise payable to me, directly to Palm Beach Center for Periodontics & Implant Dentistry, P.A. and I authorize the use of the signature on all insurance submissions.
Signature of Patient / Legal Guardian*

Clear
Date*

MonthDayYear
Doctors Signature

Clear
Date

MonthDayYear
Should be Empty:

Patient Information

Responsible Party

Insurance Information

Additional Insurance Information