Adult New Patient Information & History

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

First Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Sex *

Male Female
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

City State

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

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

Health Care Professional(s)
Dentist's Name *

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

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

Dental Insurance Information
Do you have dental insurance? *

Yes No
Name of Policy Holder *

First Name Last Name
Date of Birth *

Month Day Year
Date
Social Security Number *
Employer *
Relationship to Patient *
Employer's Address *

Street Address

Street Address Line 2

City State

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

City State

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 *

Month Day Year
Date
Should be Empty: