ADULT PATIENT INFORMATION
Date __________________
Last Name ______________ First Name ______________ Middle Name _________________
Prefer to be called _____________ Birthday ____/_____/_____ Age _______ Sex ____
month
day
year
e-mail _________________________________________________________________________
Home Address ___________________________ City ________ State ____ Zip __________
Cell Phone ___________________________ Work/Home Phone _________________________
Occupation ___________________________ Employer ________________________________
Patient fluent in the following languages ______________________________________
Has any member of your family been treated by this office? Y/N/WHOM ____________
Who may we thank for referring you to our office? ______________________________
Marital Status ____________________
Do you have any children? Y/N
Children's names and birthdates: _______________________________________________
Patient's Dentist ____________________ Patient's Physician _____________________
Date of last dental cleaning at the Dentist ____/____
month
year
Is there any pending dental work at the Dentist? _______________________________
BILLING INFORMATION
If responsible party is other than self, fill out the following questions:
Person responsible for this account:
Last Name ______________ First Name _______________ Middle Name ________________
SS# ____________________ Relationship to patient _______________________________
Billing Address _____________________________________ City _______ Zip _________
Occupation ______________ Cell phone _______________ Work phone ________________
Employer's Name ________________________________________________________________
INSURANCE INFORMATION
Is patient covered by orthodontic insurance? Y/N
Name of Policy Holder __________________ Relationship to Patient _______________
Dental insurance company _____________________ Insured’s DOB ____/____/____
month
day
year
SS# Insured: ________________________ 1-(800) __________________________________
Group Name: _________________________ Group #: _________________________________
Signature_____________________________
Date_______________
MINOR PATIENT INFORMATION
Date __________________
Last Name ____________
First Name ____________
Preferred to be called __________
Middle Name _______________
Birthday ____/____/____
month
day
Age______ Sex ___
year
Home Address ___________________________ City ________ State ____ Zip _______
Home Phone _________________ School ___________________________ Grade _______
Mom/Dad e-mail ______________________________________________________________
Patient's Dentist ___________________ Patient's Pediatrician ________________
Date of last dental cleaning at the Dentist ____/____
month
year
Is there any pending dental work at the Dentist? ____________________________
Patient fluent in the following languages ___________________________________
Has any member of your family been treated by this office? Y/N/WHOM _________
Who may we thank for referring you to our office? ___________________________
Mother's Name ___________ Occupation ___________ Cell phone _________________
Father's Name ___________ Occupation ___________ Cell phone _________________
Mom’s spoken languages ______________ Dad’s spoken languages ________________
BILLING INFORMATION
Person responsible for this account:
Last _______________ First ______________ Middle _________________
SS# _________________
Relationship to patient __________________
Billing Address ______________________________________ City _______ Zip_______
Cell phone ___________________________ Work phone ____________________________
Employer's Name ________________________________
INSURANCE
Is patient covered by orthodontic insurance? Y/N
Name of Policy Holder ____________________ Relationship to Patient ___________
Dental Insurance company ________________________ Insured’s DOB
____/____/____
month
day
year
SS# Insured:__________________________ 1-(800)________________________________
Group Name: __________________________ Group #:_______________________________
Signature______________________________
Date________________