Last Name:
First Name:
Middle Initial:
Mailing Address: (Street, City, State, Zip)
Birthday:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Do you want Email reminders?
Social Security Number:
Drivers License Number:
Occupation:
Employer:
Employer Phone:
Employer Address: (Street, City, State, Zip)
ln Case of Emergency Contact
Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
Whom can we thank for referring you to us?
Account Information
Last Name:
First Name:
Middle Initial:
Mailing Address: (Street, City, State, Zip)
Birthday:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Do you want Email reminders?
Social Security Number:
Drivers License Number:
Occupation:
Employer:
Employer Phone:
Employer Address: (Street, City, State, Zip)
Insurance Company:
ID Number:
Group Number:
Last Name:
First Name:
Middle Initial:
Mailing Address: (Street, City, State, Zip)
Birthday:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Do you want Email reminders?
Social Security Number:
Drivers License Number:
Occupation:
Employer:
Employer Phone:
Employer Address: (Street, City, State, Zip)
Insurance Company:
ID Number:
Group Number:
I do authorize and give consent to my Dentist and his/her Dental Team to administer treatment, including, but not limited to local anesthesia, analgesia, and other such treatment which may be necessary for the above named patient.
I understand that I am responsible for all costs of dental treatment. I aulhorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I authorize the dentist to release all infomation necessary to secure payment of benefits.
Patient or Responsible Party Signature: X
Date:
Email:
ADAIDM/12-08