New Patient Information Form - Rhoades Dentistry

PATIENT INFORMATION

Please fill out all pertinent information for the PATIENT.

Hidden

Date

Legal Name*

First Middle Last

Prefers to go by

Patient's SS#

Birth Date

Name of Guardian

First Last

Relationship of Guardian

Driver's License #

Patient's last dental visit

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Email address

Ho would you prefer we contact you?

Email
Cell
Home
Work

Employer

Occupation

Work Address

Street Address Address Line 2 City State ZIP Code

Years Employed

Spouse's Name

First Middle Initial Last

Spouse's Employer

Spouse's Occupation

Years employed

Spouse's SS#

Spouse's Birhtdate

Spouse's Work Phone

Spouse's Cell Phone

Who may wse thank for referring you to our office?

Did you make your appointment after visiting our website?

Yes
No

Did you notice our sign?

Yes
No

Was our location a factor in choosing us?

Yes
No

Have other family members been to this office?

Yes
No

Whom?

INSURANCE INFORMATION

Insured's Name

First Last

Group #

Insured ID

Insured SS#

Insured's Date of Birth

Do you have dual coverage?

Yes
No

EMERGENCY INFORMATION

Emergency Contact Person

First Last

Home Phone

Alternate Phone

Relationship to Patient

Address

Street Address Address Line 2 City State ZIP Code

SIGNATURE

Acknowledge and SIgn*

I understand I am responsible for my account. If I have dental insurance the claims will be filed for me, and I will be responsible for any remaining balance. I also understand this office values my time and will make every effort to honor my appointment times. Likewise, if I fail to keep my appointments, within 24 hours notice, I understand I will be charged for those items and/or dismissed from the practice. If you are a parent of a minor child and are bringing them for treatment in this office, you are responsible for the child's balance.

Name

First Last

Relationship to Patient

Name

This field is for validation purposes and should be left unchanged.