Adult New Patient Registration Form

Welcome! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Today's Date:

ABOUT YOU

Name:     Male Female

Email:     I prefer to be called:

Date of Birth:     Age:     Social Security #:     Driver's License #:

Address:     Apt:     City:     State:     Zip:

Marital Status: Single Married Divorced Widowed Separated

Home Phone:     Cell Phone:

Name of Employer:     Work Phone:

Employer Address:

Occupation:     How long employed there?

Where and when are the best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

Previous/Past Dentist:     Last Visit Date:

SPOUSE INFORMATION

Name:

Date of Birth:     Age:     Social Security #:     Driver's License #:

Name of Employer:     Work Phone:

INSURANCE COVERAGE

  Primary

Insurance Co. Name:     Insurance Co. Address:

Insurance Co. Phone:     Group # (Plan,Local, or Policy#):

Insured's Name:     Relation:

Insured's Birth Date:     Insured's SS#:

Insured's Employer:     Employer's Address:

  Secondary

Insurance Co. Name:     Insurance Co. Address:

Insurance Co. Phone:     Group # (Plan,Local, or Policy#):

Insured's Name:     Relation:

Insured's Birth Date:     Insured's SS#:

Insured's Employer:     Employer's Address:

Person Responsible for Account

Name:     Relation:

Home Phone:     Work Phone:     Employer:

Billing Address:

Social Security #:     Driver's License #:

In the event of an emergency, is there someone that lives near you that we should contact?

Name:     Relation:

Home Phone:    Work Phone: