Submit Patient Information

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Patient Information

Patient Name
Gender MaleFemaleOther
Family Status SingleMarriedDivorcedWidowed
Birth Date
SS#
Email
Cell Phone
Address
Driver's License No.
Driver's License State

Employment Information

Employer Name
Employer Phone
Employer Address
Permission to contact at work? YesNo
Best time to contact

Insurance Information

Name of Insured
Insured's Date of Birth
Relationship to Insured SelfSpouseChildOther

Dental Information

Immediate Concern

Previous Dentist
Check all that apply:
Dry mouthTeeth sensitive to hot/cold/sweetsGums bleedUnpleasant taste/odor
Additional Comments

Medical History

Preferred Name

Indicate which conditions apply:

AnxietyArthritisFibromyalgiaCholesterolSeasonal AllergiesSinus ProblemsOther
If other, please describe

Preferred Pharmacy
Are you currently taking any medications? YesNo

Consent & Acknowledgements

I understand and agree to the financial policy.
I understand and agree to the HIPAA disclosure.
I have reviewed and confirmed my medical history.
I grant permission for secure online storage of my information.

Signature
Date
Relationship to Patient SelfParent/GuardianOther