Patient, General and Insurance Information.
After completing this page, please press the submit button below. Your information will be encrypted and securely forwarded, in compliance with HIPAA protocol.
Patient Name
*
First Name
Last Name
Preferred Name/Nickname:
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Preferred Title:
Miss
Ms.
Mrs.
Mr.
Dr.
None
Marital Status:
Single
Married
Widower
Separated
Divorced
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone
*
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
*
example@example.com
Social Security Number:
*
Occupation/Title
*
Employer
Preferred Method of Communication (Pick as many as you'd like)
Mobile Phone
e-mail
Text
Home Phone
Work Phone
Post Card
Other
Financially Responsible Person (FRP) Information
Please fill if the financially responsible person is other than the patient that will be receiving dental care.
FRP: Relationship to Patient
*
Self
Spouse
Parent
Guardian
Other
Not applicable
FRP: Full Name
First Name
Last Name
FRP Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FRP: Social Security Number
FRP: Birth Date
-
Month
-
Day
Year
Date
PRF: Email
example@example.com
FRP: Phone
-
Area Code
Phone Number
How did you hear about us?
Family Member
Friend
Co-worker
Internet search
Physician's recommendation
Other
Please let us know if there is someone to thank for recommending.
First Name
Last Name
HIPAA permission is granted to: (required to allow discussion of treatment & administrative matters)
Full Name
First Name
Last Name
Relationship
Email
example@example.com
Phone Number
-
Area Code
Phone Number
In Case of Emergency: Please contact
Full Name
First Name
Last Name
Relationship to you
Parent
Sibling
Guardian
Friend
Spouse
Partner
Daytime Phone Number
-
Area Code
Phone Number
Insurance Information (If applicable)
Relationship to Policy Holder:
Self
Spouse
Child
No insurance coverage
Other
Policy Holder (PH) Information (If applicable)
PH: Full Name
First Name
Last Name
PH: Date of Birth
-
Month
-
Day
Year
Date
PH: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PH: Social Security Number
PH: Insurance Identification Number (ID#)
PH: Group Number G# / Policy Number P#
Dental Insurance Company Name
Employer / Association Information (if applicable)
Parent Company/ Association
Phone Number
-
Area Code
Phone Number
Health Savings Account (HSA), Flexible Savings Account (FSA) information (if applicable)
Can you participate in a HSA or FSA?
HSA
FSA
No
Not Sure
N/A
Other
Signature
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Submit
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