Responsible Party

First Name:

Last Name:

Middle Initial

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Sex

Marital Status

Birth Date

Social Security Number

Insured Party/Employment

First Name

Last Name

Middle Initial

Employer

Insurance Company

ID Number

Social Security Number

Birth Date

Group Number

Secondary Insured Party/Employment

First Name

Last Name

Middle Initial

Secondary Employer

Secondary Insurance Company

ID Number

Social Security Number

Birth Date

Group Number

Patient Information

First Name

Last Name

Middle Initial

Address

City

State

Zip

Home Phone

Cell Phone

Social Security Number

Birth Date

Sex

Health Condititions

Other Health Condititions

List all Current Medications

Allergies

Primary Reason for Visit

Have you ever had any surgeries?

Explain

Have you ever had any complications following dental treatment?

Are you under the care of a physician?

If so why?

Name of Primary Care Physician

Phone Number

How did you find us:

Referred by:

* Please print,sign and bring into the office. Thank you *

Signature of Responsible party:_______________________Date:___________

Responsible Party

Insured Party/Employment

Secondary Insured Party/Employment

Patient Information

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* Please print,sign and bring into the office. Thank you *