PATIENT INFORMATION (CONFIDENTIAL)
 
First Name Middle Name Last Name Date
 
Address City State Zip
 
Email Cell Phone Home Phone
 
SS#/SIN (SS is not stored) Birth Date
 
Check Appropriate :         Minor                Single                Married                Divorced                 Widowed                 Separated
 
If College Student: F.T./P.T. Name of School City: State:
 
Patient's or Parent's Employer Work Phone Ext
 
Business Address City State Zip
 
Spouse or Parent's/Guardian's Name Employer Work #
 
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 State Zip Home Phone
 
Driver's Licence # Birth date SS#/SIN
 
Employer Work Phone Ext
 
Is this person currently a patient in our office?     Yes        No
 
Do You Have Dental Insurance?     Yes        No
 
INSURANCE INFORMATION
 
Name of Insured     Relationship to Patient
 
Birth Date SS#/SIN Date Employed
 
Name of Employer Work Phone Ext
 
Employer Address City State Zip
 
Insurance Co Phone # Group # Policy/ID #
 
Insurance Co Address City State Zip
 
Do you have any additional Insurance     Yes        No
 
If Yes Complete the following
Name of Insured     Relationship to Patient
Birth Date SS#/SIN Date Employed
Name of Employer Work Phone Ext
Employer Address City State Zip
Insurance Co Phone # Group # Policy/ID #
Insurance Co Address City State Zip
 
Signature of Patient or Parent/Guardian if minor: _____________________________________