New Patient

Please Read

This form was designed for anyone who hates to fill out all those forms at a doctors office when going for an initial visit. Although you will need to fill out a medical history questionnaire at your first visit to our office, submitting this form beforehand will save you considerable time. Upon receiving this form, we will transfer the information to our regular paper form, and have you complete and sign it upon your arrival. Although we will need all the information requested on this form, you need only fill in the fields you desire for now. Information not submitted on this form will be requested of you in person upon arrival at our office.

This form is intended as a convenience for our on-line new patients. There is no requirement to submit this form. You may simply elect to fill out our forms at your first visit if you prefer.

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
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
Spouse's Work Phone	Extension:
Social Security #
Birthdate
D.L. Number
Responsible Party
Person Responsible for Account
Work Phone
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
Work Phone	Extension:
Home Phone

New Patient

Please Read

About You

Spouse Information

Responsible Party

Primary Dental Insurance

Secondary Dental Insurance

Emergency