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 needs assistance, please ask us-
we will be happy to help.
Welcome
Patient #
SS #/SIN
Date
Problem while submitting data, try after some time.
Patient Information
(CONFIDENTIAL)
Name
Birthdate
Home Phone
Address
City
State/Prov
Zip/P.C.
Email
Cell Phone
Check Appointment Box:
Minor
Single
Married
Divorced
Widowed
Separated
If Student, Name of School/College
City
State/Prov
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 thanks 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 following methods of payment. Please check the option you prefer. Payment in full at each appointment.
Cash
Personal Check
Credit Card
VISA
Master Card
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 #:
Inc 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?
Yes
NO
IF YES, COMPLETE THE FOLLOWING:
Name of insured
Relationship to Patient
Birthdate
SS#/SIN
Date of 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
$