Adult New Patient Information & History

Adult New Patient Information & History
Patient's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Occupation*
Employer*
Years Employed*
Name of Spouse/Closest Relative*

First NameLast Name
Relation*
Spouses Occupation*
Spouses Employer*
T-Shirt Size*
Who can we thank for referring you?*

Health Care Professional(s)
Dentist's Name*

First NameLast Name
Dentist's Phone Number*
Please enter a valid phone number.
Physician's Name*

First NameLast Name
Physician's Phone Number *
Please enter a valid phone number.

Dental Insurance Information
Do you have dental insurance?*

YesNo
Name of Policy Holder*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Employer *
Relationship to Patient*
Employer's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer's Phone Number*
Please enter a valid phone number.
Insurance Company*
Member ID Number*
Group Number*
Insurance Company Phone Number*
Please enter a valid phone number.
Insurance Company Address*

Street Address

Street Address Line 2

CityState

Zip Code

Notice of Privacy Practices

Health Information Access

Note: If you wish to add or teminate information access to or from the list below, you must submit your request in writing to our office.
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number *
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number *
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number *
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number *

Signature
Parent/Guardian Signature*

Clear
Date Submitted*

MonthDayYear
Date
Should be Empty: