Patient Registration & Medical History Form

Patient Name*

First Last

Date of Birth*

Sex

Are you a minor?*

Name of Legal Guardian*

First Last

Home Phone

Mobile Phone

Work Phone

Check At least One That Applies:*

Marital Status*

Email*

Mailing Address*

Street Address City State ZIP Code

Employer*

Occupation*

Who is responsible for this account?*

Relationship to patient*

Whom may we thank for referring you to our office?

Insurance Information

Your SS#*

Member ID# (Optional)

Group Number

Dental Insurance Co.*

Claims Address*

Street Address City State ZIP Code

Covered by another's insurance?*

Name of Insured*

Insured's Dental Insurance Co.*

Claims Address*

Street Address City State ZIP Code

Insured's SS#*

Insured's Member ID# (Optional)

Insured's Group Number

Insured's Date of Birth*

Name of your primary medical physician*

Phone number*