New Patient Information Form

    • PATIENT INFORMATION FORM

    • *PATIENT INFORMATION
    • REFERRING INFORMATION

    • If YES, please fill out the remaining insurance questions.

    • *PRIMARY INSURANCE INFORMATION

    • *Secondary INSURANCE INFORMATION

    • **If MINOR UNDER 18 or a guardian/parent is financially responsible for your account, please fill out the following information:

    • Who came with you today?
    • *EMERGENCY CONTACT INFORMATION

    • DRIVER’S INFORMATION (PERSON RESPONSIBLE FOR DRIVING PATIENT HOME FROM SURGERY)
    • AUTHORIZATION
    • I authorize the Doctor/Staff to perform oral surgery and/or examination for the purpose of treatment. I also authorize the taking of x-rays required as a necessary part of this examination. Additionally, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment. Furthermore, I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

    • Signature of patient or legal guardian

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