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 # *

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

New Patient Form

In Case Of Emergency

1. Insurance

2. Insurance

If someone other than the PATIENT is responsible for payment, complete the following

By hitting submit:

Clovis/Fresno Dentistry - K&H Dental Group - 1550 Shaw Ave Clovis Ca 93611 - 559-840-3440