Patient Information Form

*PATIENT INFORMATION FORM
PATIENT INFORMATION
Date *
Name *
Preferred Name *
Street Address *
City *
State *
Zip *
Date of Birth *
Home# *
Cell# *
Work# *
SEX *

Male Female
Marital Status *
Email Address *
REFERRING INFORMATION
Referring Dentist
Practice Name
*INSURANCE INFORMATION
Primary Policy Holder Information
Relationship to Patient
Marital Status
Name
Date of Birth *
SSN# *
SEX

Male Female
Cell#
Work#
Email Address
Employer
Position
DENTAL Insurance
ID#
Group#
MEDICAL Insurance
ID#
Group#
Secondary Policy Holder Information
Relationship to Patient
Marital Status
Name
Date of Birth *
SSN# *
SEX

Male Female
Cell#
Work#
Email Address
Employer
Position
DENTAL Insurance
ID#
Group#
MEDICAL Insurance
ID#
Group#
*EMERGENCY CONTACT INFORMATION
Name
Email Address
Address
Relationship to Patient
Home#
Cell#
Medical Information may be discussed with
Relationship
DRIVER’S INFORMATION (PERSON RESPONSIBLE FOR DRIVING PATIENT HOME FROM SURGERY)
Name
Relationship
Phone#
File Upload

Select File(s)

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 X