New Patient Form

Please fill out the form below, or download and return this PDF document.

Step 1 of 4 - Patient/Insurance Information

Patient Information
First Name * Required
First
Middle Initial * Required
Middle
Last Name * Required
Last
Phone * Required
Email * Required
SSN * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Sex * Required
Marital Status * Required
Birthdate - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Patient Employer
Occupation
Work Phone
How would you like to be notified for upcoming appointments?
- Email
- Phone
- Text
Mobile Carrier (to receive text messages for appointments):
Insurance Information
Any Dental Insurance Coverage? * Required
Who is your carrier? * Required
ID number/Social # * Required
Person Responsible for Account * Required
Relation to Patient
Birthdate - must be mm/dd/yyyy format
MM slash DD slash YYYY
Phone
Address (if different from patient's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Permission
Emergency Contact * Required
Emergency Contact Relation * Required
Emergency Contact Phone * Required

Authorization
Consent * Required
I agree to the below statement.
I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me
I authorize the use of the signature on all insurance submissions.
I understand this practice’s Notice of Privacy Practices written in plain language. This notice provides the usage of
Initial disclosure of my health information as protected by HIPAA.
I understand this office has the right to alter this privacy in regards to my health information. If changes occur this
Initial practice will provide me with a revised notice of the privacy policy upon my request.
I instruct the dentist and/or hygienist to deliver the care that, in their professional judgement, can best help me in the
Initial restoration of my health.
Consent
I agree to the below statement.
I consent to allow photographs and/or x-rays to be used for demonstrations, marketing material, patient education, etc.
Consent * Required
I agree to the below statement.
I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions.
Consent * Required
I agree to the below statement.
I have answered all questions regarding myself, or my dependent's medical history and present health condition fully and truthfully, including allergies. I also understand if there are any changes in my, or my dependents health I am to inform the doctor at my next appointment.
Consent * Required
I agree to the below statement.
I agree to provide a minimum of 24 hour notice if I need to change my appointment for any reason. I understand if I fail an appointment I may be charged a fee. Failure to show for a second appointment may result in dismissal from the practice.
Consent * Required
I agree to the below statement.
I instruct the dentist to deliver care that, in their professional judgement, is necessary in the restoration of my health once they've been discovered and discussed.
Consent * Required
I agree to the below statement.
State and federal laws require us to maintain the privacy or your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. This form is available online for your convenience, if you prefer a paper copy, please feel free to contact us.
Whom may we thank for referring you/ how did you hear about us? * Required
Full Name * Required
Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY

New Patient Form

Step 1 of 4 - Patient/Insurance Information

Patient Information

Insurance Information

Permission

Patient Medical History

Do you have or have you ever had:

Are you:

Authorization

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