Vargo Orthodontics HHF-Form

PATIENT INFORMATION:

Date:

Patient's Name

SS#

Address: Street

City

State

Zip

Home Phone:

Birthdate

School

Grade

If patient is a minor, give parent’s or guardians name

Whom may we thank for referring you to our ofﬁce?

Are you interested in our valet service?

Yes No

Responsible Party Information

Name

Marital Status

Residence: Street

City

State

Zip

Own Rent

Mailing Address Street

City

State

Zip

How long at this address

Home Phone

Work Phone

Previous Address (if less than 3 yrs.) Street

City

State

Zip

Cell Phone

Cell Carrier

Social Security #

Birthdate

Relationship to Patient

Employer

Occupation

No. Years Employed

Spouse’s Name

Relationship to Patient

Employer

Occupation

No. Years Employed

Social Security #

Birthdate

Work Phone

Cell Phone

Orthodontic Insurance Information

Policy Holder’s Name

Relationship to Patient

SSN

Insurance Company

Group No.

ID No.

Insured’s address if different than patient:

Insurance Co. Phone:

Policy Holder’s Employer

Do you have dual coverage? Yes No

Policy Holder’s Name

Relationship to Patient

SSN

Insurance Company

Group No.

ID No.

Insured’s address if different than patient:

Insurance Co. Phone:

Policy Holder’s Employer

Emergency Information

Name of nearest relative not living with you

Complete Address

Phone

I understand that where appropriate, credit bureau reports will be obtained.

Signature (Parent’s signature if minor)

Print Name

Relationship to Patient

Updates (date & initial)

CONFIDENTIAL (for record and pretreatment evaluation)

PATIENT INFORMATION:

Responsible Party Information

Orthodontic Insurance Information

Emergency Information

Joseph K. Vargo, D.M.D., M.S.
Orthodontist

If under 18:

PATIENT INFORMATION:

Responsible Party Information

Orthodontic Insurance Information

Emergency Information

Joseph K. Vargo, D.M.D., M.S.Orthodontist

If under 18:

Joseph K. Vargo, D.M.D., M.S.
Orthodontist