Confidential Patient Information
*Last Name:
*First Name:
Nickname:
Email:
*Gender:
Male
Female
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Home Phone:
School:
Grade:
Employed By:
Occupation:
Business Phone:
Whom may we thank for recommending us?
Name of Dentist:
Date of last visit:
Related Patients That Are Or Have Been Under Our Care:
Parent Information (please complete if patient is a minor)
Parent 1
First Name:
Middle Initial:
Last Name:
Address (if different from patient):
City:
ST:
Zip:
Home Phone:
Work Phone:
Email Address:
Employer:
Employer Address:
City:
ST:
Zip:
Parent 2
First Name:
Middle Initial:
Last Name:
Address (if different from patient):
City:
ST:
Zip:
Home Phone:
Work Phone:
Email Address:
Employer:
Employer Address:
City:
ST:
Zip:
Information About Person Responsible For This Account (if different from patient)
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Relationship to Patient:
Self
Father
Grandparent
Guardian
Mother
Parents
Spouse
Step Father
Step Mother
Other
Employer:
Occupation:
*Address:
*City:
*State:
*Zip:
*Main Phone:
Business Phone:
Email:
If divorce is involved, who is the custodial parent?
May patient information be released to the non-custodial parent?
Yes
No
Orthodontic Insurance Information
Primary Insured's Name:
Subscriber ID Or Soc Sec #:
Insurance Company Name:
Group No:
Date Of Birth:
Insurance Co. Address:
Insured's employer:
Do you have dual orthodontic coverage?
No
Yes
2nd Insured's Name:
Subscriber ID Or Soc Sec #:
Insurance Company Name:
Group No.:
Date Of Birth:
Insurance Co. Address:
Insured's employer:
Emergency Information
Contact Person In Case Of Emergency:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Step Father
Step Mother
Other
Patient signature (parent if minor)
Date: