New Patient Information Form

PATIENT INFORMATION FORM

*PATIENT INFORMATION
Name (Last, First) *
Preferred Name *
Mailing Address *
City *
State *
Zip *
Date of Birth *
Gender *

M F U
Social Security# *
Marital Status *
Home/Cell# *
May we text you? *

Yes No
Email Address *
May we email you? *

Yes No
Drivers license or if minor, drivers license of financial party

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REFERRING INFORMATION
Referring Dentist / DOCTOR
Practice Name
Who is your MEDICAL DOCTOR ?
Office Name
Do you have insurance? *

Yes No
If YES, please fill out the remaining insurance questions.
*PRIMARY INSURANCE INFORMATION
Is this PRIMARY Insurance *

MEDICAL DENTAL Both?
Insurance Company Name *

Insurance Claims Billing Address & Phone Number (usually on the back of the card) *
Policy Holder’s Relationship to Patient ( SELF, Spouse, Child, etc) *

Subscriber/Policy Holder ID # *
Group ID # *
Policy Holder’s Employer *
Policy Holder’s Date of Birth *
Policy Holder’s Social Security # *
Policy Holder’s Cell# *
Email Address *
front and back images

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Do you have Second insurance?

Yes No
If YES, please fill out the remaining insurance questions.
*Secondary INSURANCE INFORMATION
Is this Secondary Insurance *

MEDICAL DENTAL Both?

Insurance Company Name *
Insurance Claims Billing Address & Phone Number (usually on the back of the card) *
Policy Holder’s Relationship to Patient ( SELF, Spouse, Child, etc) *
Subscriber / Policy Holder ID # *
Group ID # *
Policy Holder’s Employer *
Policy Holder’s Date of Birth *
Policy Holder’s Social Security # *
Policy Holder’s Cell# *
Email Address *
front and back images

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**If MINOR UNDER 18 or a guardian/parent is financially responsible for your account, please fill out the following information:
Father/ Mother/Guardian Name
Date of Birth *
Driver’s License
Social Security #
Mailing Address
Phone Number
*EMERGENCY CONTACT INFORMATION
Name
Email address
Address
Relationship to Patient
Home#
Cell#
Private Information may be discussed with
Relationship
DRIVER’S INFORMATION (PERSON RESPONSIBLE FOR DRIVING PATIENT HOME FROM SURGERY)
Name
Relationship
Phone#
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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