Patient Information

About the Patient
Today's Date*
MM slash DD slash YYYY
Is the patient an Adult or Child*
- Adult
- Child
Male or Female*
- Male
- Female
Age
Marital Status*
Date of Birth*
MM slash DD slash YYYY
Name*
First Last
Preferred Name
Name
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Child's Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Name of School
Home Phone*
Cell Phone
Work Phone
Hobbies / Special Interests
Email Address
Enter Email Confirm Email
Siblings
Name Age
Siblings
Name Age
Social Security Number
About Your Employer
Employer Occupation Number of years employed
Your Dentist
Your Dentist's Name Who referred you
Date of your last visit with your Dentist?
MM slash DD slash YYYY
Who may we thank for referring you?
Name

Responsible Party Information*
First Last
Billing Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone
Work Phone
Emergency Contact*
First Last
Relationship to Patient*
Home Phone*
Cell Phone
Work Phone

Dental Insurance
Primary Insurance Name*
First
Primary Insurance Address
Street Address City State / Province / Region ZIP / Postal Code
Primary Insurance Phone*
Group / Policy Number*
Insured's Name*
First Last
Relationship to Patient*
Insured's Date of Birth*
MM slash DD slash YYYY
Insured's Employer
Insured's Social Security Number*
Do you have Orthodontic Coverage?
- Yes
- No
- Don't know
Do you have Secondary Dental Insurance*
- Yes
- No
Secondary Insurance Name*
First
Secondary Insurance Address
Street Address City State / Province / Region ZIP / Postal Code
Insurance Phone*
Group / Policy Number*
Insured's Name*
First Last
Relationship to Patient*
Insured's Date of Birth*
MM slash DD slash YYYY
Insured's Employer
Insured's Social Security Number*
Do you have Orthodontic Coverage?
- Yes
- No
- Don't know

About the Patient