Welcome to PEPPERMINT DENTAL!
Tnriny'?: Date:
PATIENT INFORMATION
Pntif^nt'<:
Nnme
Preferred
Last
□
Name
□
Male
Female
First
Hnme Address
Street
Home
(for
Fmoil
City
Phone
#
in^ur)
Who
Cell
Birthdate
mav
we
/
thank
State
#
/
for
Work
□
Sinale
referring
Zip
#
□
Married
□
Other
you?
Othftr fomily members seen bv us
Employer
Occupation
Would you like to receive reminder messages/calls for your appointments by □ email □ text □ phone
N E I G H B O R O R R E L AT I V E N O T L I V I N G W I T H Y O U
N o m e
Relation
Home
Phone
#
Other #
S P O U S E I N F O R M AT I O N
His/Her Name
Birthdate
Cell#
/
/
SSN
W o r k #
PA R E N T S I N F O R M AT I O N F O R C H I L D
□ Responsible for account
Mother's Name
Home Phone #
Cell#
Work #
Email
Birthdate
/
/
□ Responsible for account
Father's Name
Home Phone #
Cell#
W o r k #
Email
Birthdate
Parent's Marital Status
/
/
□ Single □ Married □ Widowed □ Divorced □ Other
INSURANCE
Primary Dental Insurance Name
Phone
#
Insurance Co. Address
street
Group/Policv
#
City
Subscriber's
Subscriber's ID#/SSN
Name
state
Zip
Relationshio to Patient
Subscriber's Birthdate / / Subscriber's Emolover
Secondarv Dental Insurance Name
Phone #
Insurance Co. Address
street
Group/Policy
Subscriber's ID#/SSN
#
City
Subscriber's
Name
state
Zip
Relationshio to Patient
Subscriber's Birthdate / / Subscriber's Emolover