Patient Information

Patient Information

Ridgeview Dental, 18130 Wright St, Omaha, NE 68130
Patient Name:*
Date of Birth:*

MonthDayYear
SS # / SIN (Enter 9 digits):
Home Phone:
Cell Phone:*
Address:*
Email:*
Marital Status:

MinorSingleMarriedDivorcedWidowedSeparated
Patient is Student:

YesNo
Name of School / College:
Student is:

Full TimePart Time
Address:
Patient or Parent / Guardian's Employer:
Work Phone:
Address:
Spouse or Parent / Guardian's Name:
Employer:
Work Phone:
Whom may we thank for referring you?
Emergency Contact Name:*
Emergency Contact Number:*
RESPONSIBLE PARTY (Please complete all information if different than patient)
Name of Person Responsible for this Account:
Relationship to Patient:
Address:
Home Phone:
Cell Phone:
Email:
Driver's License #:
Date of Birth:

MonthDayYear
Financial Institution:
Employer:
Work Phone:
SS # / SIN:
Is this person currently a patient in our office?

YesNo
For your convenience, we offer the following methods of payment. Please Select the option you prefer. Payment in full at each appointment.

CashPersonal CheckCredit CardVISAMaster Card
INSURANCE INFORMATION
Name of Insured:
Relationship to patient:
Date of Birth:

MonthDayYear
SS # / SIN:
Date Employed:
Name of Employer:
Union or Local #:
Work Phone:
Address of Employer:
Insurance Company:
Group #:
Policy / ID #:
Ins. Co. Address:
How much is your deductible?
How much have you used?
Max. annual benefit:
Do you have any additional Insurance?

YesNo
Name of Insured:
Relationship to patient:
Date of Birth:

MonthDayYear
SS # / SIN:
Date Employed:
Name of Employer:
Union or Local #:
Work Phone:
Address of Employer:
Insurance Company:
Group #:
Policy / ID #:
Ins. Co. Address:
How much is your deductible?
How much have you used?
Max. annual benefit:
Should be Empty:

Patient Information

RESPONSIBLE PARTY (Please complete all information if different than patient)

INSURANCE INFORMATION