First Name _________________________Last Name _________________________Middle Initial _____ Preferred Name ______________
Circle one Married Divorced Separated Single Widowed Minor Birth Date ______/______/______ Sex: Male / Female
Mailing Address __________________________________________________________________________________________________
City ____________________________________State_____________________________________________ Zip____________________
Home Phone ________________________Cell ___________________________ Work _________________________ Ext. ____________
Responsible party
if different than patient _______________________________Mailing Address _________________________________________________
Phone number _____________________________________ Work number ___________________________________ Ext_____________
If patient is minor, parent’s name______________________________________________________________________________________
How did you hear about us?
__________________________________________________________________________________________
Are you a pre medication patient? Yes / No If yes what medication _____________________________________________________
Employment status: full time part time retired Unemployed
If full time college student, please include the following.
College Name _________________________________________Address____________________________________________________
City _____________________________State___________________ Zip Code ______________________________________________
E-mail Address____________________________________________________ Do you wish to be contacted by E-mail? Yes / No
Please circle all that apply Responsible party Patient Primary policyholder Secondary policyholder
DENTAL INSURANCE ONLY:
Primary Insurance Policy Holder Name ______________________________________ DOB of Policy Holder _______/________/________
Name of Insurance Company____________________________________________ Insurance Address__________________________________
City_______________________________ State _________________________________Zip _________________________________________
Insurance Company Phone________________________________ Employer Name__________________________________________________
Employer Phone._____________________________________ Employer Address___________________________________________________
City __________________________________ State ___________ Zip _________________________
ID Number__________________________________ Group Number___________________ Relationship to patient _______________________
Secondary Insurance Policy holder Name ________________________________________ DOB of Policy holder ______/_______/________
Insurance Company__________________________________________ Insurance Co Address_________________________________________
City____________________________________________ State ________________________________.Zip code_________________________
Insurance Company phone ____________________________________Employer Name______________________________________________
Employer Phone_______________________________________ Employer Address_________________________________________________
City___________________________________________ State ___________.Zip code ____________________________
ID Number__________________________________ Group Number______________________ Relationship to patient___________________
PATIENT REGISTRATION