Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help.
Patient Information (CONFIDENTIAL) Patient#: SS#/SIN: Date:
Name:		Birthdate:		Home Phone:
Address:				City:			State/Prov:		Zip/P.C.:
Email:				Cell Phone
Check Appropriate Box:	Minor Single Married Divorced Widowed Separated
If Student, Name of School/College:		City:		State/Prov:			Zip/P.C.:		Full time	Part time
Patient or Parent/Guardian's Employer:		Work Phone:
Business Address:		City:		State/Prov:			Zip/P.C.:
Spouse or Parent/Guardian's Name:		Employer:		Work Phone:
Whom may we thank for referring you?
Person to contact in case of emergency						Phone:
Responsible Party
Name of Person Responsible for this Account:						Relationship to Patient:
Address:						Home Phone:
Email:						Cell Phone:
Driver's License #:						Birthdate:		Financial Institution:
Employer:						Work Phone:		SS#/SIN:
Is this person currently a patient in our office?	Yes No
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.	Cash Personal Check Credit Card VISA MasterCard I wish to discuss the office's payment policy.
Insurance Information
Name of Insured:						Relationship to Patient:
Birthdate:		SS#/SIN:				Date Employed:
Name of Employer:		Union or Local#:				Work Phone:
Address of Employer:			City:			State/Prov:			Zip/P.C.:
Insurance Company:			Group #:			Policy/ID #:
Ins. Co. Address:			City:			State/Prov:			Zip/P.C.:
How much is your deductible?				How much have you used?			Max. annual benefit
DO YOU HAVE ANY ADDITIONAL INSURANCE? IF YES COMPLETE THE FOLLOWING:	Yes No
Name of Insured:						Relationship to Patient:
Birthdate:		SS#/SIN:				Date Employed:
Name of Employer:		Union or Local#:				Work Phone:
Address of Employer:			City:			State/Prov:			Zip/P.C.:
Insurance Company:			Group #:			Policy/ID #:
Ins. Co. Address:			City:			State/Prov:			Zip/P.C.:
How much is your deductible?				How much have you used?			Max. annual benefit