New Patient

Please Read

This form was designed for people who hate to fill out paperwork at a doctor’s office at the initial appointment. Although you will need to complete a medical history questionnaire at your first visit to our office, submitting the information below saves considerable time at check-in. When we receive your information, we’ll transfer it to our new patient form, then have you complete and sign it upon arrival. Although we’ll ultimately need all of the information requested below, you need only complete the fields you want to for now.

This form is provided as a convenience for our new patients. You are under no obligation to submit the information prior to your first visit. Patients may elect to fill out all forms at the initial appointment.

About You

Name

Gender

I prefer to be called

Birthdate

Age

Social Security #

Street Address

City      

 

State       Zip 

Marital Status

Home Phone

    

Pager

Cell Phone

     

Other

E-mail Address

Work Phone

     

Extension 

D.L. Number

Employer

Employer's Address

How long there?

Occupation

Whom may we thank for referring you?

Other family members seen by us

Previous/Present Dentist

Last Visit Date

Spouse Information

Spouse's Name

Spouse's Employer

Spouse's Work Phone    

Extension:

Social Security #

Birthdate

D.L. Number

Responsible Party

Person Responsible for Account

Work Phone

  

Extension:

Home Phone

Billing Address

Relation

Social Security #

Employer

Drivers License #

Primary Dental Insurance

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Group # (Plan, Local or Policy #)

Insured's Name

Relation

Insured's Birthdate

Insured's SS #

Insured's Employer

Secondary Dental Insurance

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Group # (Plan, Local or Policy #)

Insured's Name

Relation

Insured's Birthdate

Insured's SS #

Insured's Employer

Emergency

In the event of an emergency, is there someone who lives near you that we should contact?

His/Her Name

Work Phone

 

Extension:

Home Phone

 


4364 N. Josey Lane • Carrollton, Texas 75010


© 2000 Glen D. Blanchard, DDS • Site designed and maintained by TNT Dental