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New Patient Form
Name
*
First
Last
Mailing Address (Address, City, State, Zip)
*
Former Dentist
*
Social Security #
*
Work/Cell Phone
*
Birth Date (MM/DD/YYYY)
*
Date of Last Dental Exam
*
Spouse/ Parent Name
*
Phone
*
Social Security #
*
How do you intend pay?
*
Cash
Check
Credit Card
Insurance
CareCredit
Who may we thank for referring you to this office
*
In Case Of Emergency
Relative to contact other than spouse or parent
*
Phone
*
Another person to contact other than relative
*
Phone
*
1. Insurance
Employee
*
Employer
*
Insurance Company
*
Birth Date (MM/DD/YYYY)
*
Employee SSN/ID#
*
Policy/ Group #
*
Claims Address
*
2. Insurance
Employee
*
Employer
*
Insurance Company
*
Claims Address
*
Birth Date (MM/DD/YYYY)
*
Employee SSN/ID#
*
Policy/ Group #
*
If someone other than the PATIENT is responsible for payment, complete the following
Name of responsible party
*
Phone
*
Address
*
Social Security #
*
Relationship to Patient
*
By hitting submit:
I acknowledge that I am financially responsible for all chargers whether or not they are covered by insurance. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the act of submitting agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize the doctor to release treatment information and x-rays.
Submit
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New Patient Form
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