New Patient Form

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Social Security Number * 🛈

Date of birth: * +

Marital status *

Single

Married

Divorced

Widowed

How did you hear about our practice *

Insurance Information

	Primary Insurance	Secondary Insurance
Subscriber's Name	Primary Insurance	Secondary Insurance
Subscriber's ID	Primary Insurance	Secondary Insurance
Date of Birth	Primary Insurance	Secondary Insurance
Relationship to Subscriber	Primary Insurance	Secondary Insurance
Employer Name	Primary Insurance	Secondary Insurance
Employer Phone	Primary Insurance	Secondary Insurance
Insurance Company	Primary Insurance	Secondary Insurance
Insurance Group	Primary Insurance	Secondary Insurance
Insurance Phone	Primary Insurance	Secondary Insurance

Responsible Party

If you are a minor, please complete the responsible party information below.

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Cell Number

Work Number

Other Phone Number

Date of birth

Email Address

Emergency Contact

First Name *

Last Name *

Best phone number to reach them *

Type of number this is *

Authorization

I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child's) health care, advice, and treatment to another dentist, or for evaluating and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to a dentist or dental group and understand that my insurance benefits may pay less than the actual bill for services and that I am responsible for any services not paid or covered by my insurance benefits and any account balance.

ELECTRONIC COMMUNICATIONS. I consent to receive HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment, and health care operations. I understand that there is no obligation to receive these electronic communications.

I attest to the accuracy of the information on this page.

Signature (sign with mouse) *

clear

Date * +