New Patient Form

PATIENT INFORMATION
Name*
First Middle Last
Social Security Number
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Patient Email
Patient Birthdate
Patient Gender
- Male
- Female
Patient Marital Status
- Minor
- Single
- Married
- Widowed
- Separated
- Divorced
Patient Employed by
Occupation
Business Phone
Person to notify in case of emergency
Emergency Home Phone
Emergency Cell Phone
Whom may we thank for referring you?
Name you prefer to be called
Other family members seen by us

PRIMARY INSURANCE
Person Responsible for Account*
First Middle Last
Social Security Number
Relationship to Patient
Birthdate
Address (if different from patient)
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Email
Person Responsible Employed by
Occupation
Insurance Company Name
Group Number
Subscriber Number

ADDITIONAL INSURANCE
Is Patient covered by additional insurance?
- Yes
- No
Subscriber Name
First Last
Relationship to Patient
Birthdate
Address (if different from patient)
Street Address Address Line 2 City State ZIP Code
Social Security Number
Home Phone
Cell Phone
Subscriber Email
Subscriber Employed by
Insurance Company Name
Group Number

Health History
Physician's name
Date of last visit
Please fill out the Medical History field with any history deemed important (such as diabetes, heart disease, prosthetic devices, and/or surgeries).
Medical History
Medications
Please list any medications you are currently taking and the correlating diagnosis:
Allergies
Please list all known allergies

Authorization & Cancellation Notice
Authorization
I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the Dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the Dentist.

I authorize the insurance company indicated on this form to pay the Dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Cancellation Notice
We are proud to participate in your dental healthcare, and have set aside time for your appointment. We understand that sometimes it is necessary to cancel or change your appointment. In consideration of others who need care, we ask that if you are unable to keep an appointment with our office, that you please observe our cancellation policy, which follows

Our office requires at least 24 hours notice for all appointment cancellations. If you are unable to provide 24 hours notice, you will be billed a $50.00 charge for the scheduled appointment time. Emergency situations will be handled at the Doctor's discretion.

If you are unable to keep your appointment scheduled for the next day and our office is closed, you may cancel by leaving a message for us on our voicemail. The 24-hour rule still applies.

By checking the box below you are agreeing that you've read our "Authorization" and "Cancellation Notice", that you understand it and agree to the policies stated. Both the checkbox and your signature are required.
Confirmation Checkbox*
- I understand and agree to the stated policies.
Signature of patient/responsible party*
We do our best to confirm your dental appointment 24 hours in advance. Please list below the best contact method.
Please call me at:
Please text me at:
Please email me at:

Step 1 of 6

PATIENT INFORMATION

PRIMARY INSURANCE

ADDITIONAL INSURANCE

Dental History

Mark either "Yes" or "No" to indicate if you have had any of the following

Health History

Please fill out the Medical History field with any history deemed important (such as diabetes, heart disease, prosthetic devices, and/or surgeries).

Authorization & Cancellation Notice

Authorization

Cancellation Notice

By checking the box below you are agreeing that you've read our "Authorization" and "Cancellation Notice", that you understand it and agree to the policies stated. Both the checkbox and your signature are required.