Patient Information Confidential

Welcome

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form compeletly in ink. If you have any questions or need assitance, please ask us - we will be happy to help.

				
				Region *
			
					Patient # *
					 
					SS# / SIN
					 
					Date *

				Name *
				 
				Birthdate*
				 
				Home Phone *

				Address
				 
				City
				 
				State / Prov
				 
				Zip / PC

Email *

Cell Phone

Check Appropriate Box:

					
						 Minor 
				
						 Single 
				
						 Married 
				
						 Divorced 
				
						 Seprated 
				
						 Widowed

					If Student, Name of School/College
					 
					City
					 
					State / Prov
					 
					 Full Time 
			
					 Part Time

Patient or Patient/Guardian's Employer

Work Phone

					Business Address
					 
					City
					 
					State/Prov
					 
					Zip/PC

					Spouse or Patient/Guardian's Name
					 
					Employer
					 
					Work Phone

Whom may we thank for referring you?

Person to contact in case of emergency

Phone

Responsible Party

Name of Person Responsible for this account

Relationship to Patient

Address

Home Phone

Email*

Cell Phone

				Driver's License#
				 
				Birthdate
				 
				Financial Institution

				Employer
				 
				Work Phone
				 
				SS#/SIN

 Is this person currently a patient in our office? 

					 Yes 
			
					 No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

				
					 Cash 
			
					 Personal Check 
			
					 Credit Card 
			
					 Visa 
			
					 MasterCard 
			
					 I wish to discuss the office's payment policy.

Insurance Information

Name of insured

Relationship to patient

				Birthdate
				 
				SS#/SIN
				 
				Date Employed

				Name of Employer
				 
				Union or Local
				 
				Work Phone

				Address of employer
				 
				City
				 
				State/Prove
				 
				ZIP/PC

				Insurance Company
				 
				Group#
				 
				Policy ID#

				Ins. Co. Address
				 
				City
				 
				State/Prove
				 
				ZIP/PC

				How much is your deductible?
				 
				How much have you used?
				 
				Max annual benefit

 DO YOU HAVE ANY ADDITIONAL INSURANCE 

				Yes 
			
				 No 
		
 IF YES, COMPLETE THE FOLLOWIG:

Name of insured

Relationship to patient

				Birthdate
				 
				SS#/SIN
				 
				Date Employed

				Name of Employer
				 
				Union or Local
				 
				Work Phone

				Address of employer
				 
				City
				 
				State/Prove
				 
				ZIP/PC

				Insurance Company
				 
				Group#
				 
				Policy ID#

				Ins. Co. Address
				 
				City
				 
				State/Prove
				 
				ZIP/PC

				How much is your deductible?
				 
				How much have you used?
				 
				Max annual benefit

Welcome

Patient Information Confidential

Responsible Party

Insurance Information

Elizabeth WilliamsUnion City, NJ

Patricia WrightPassaic, NJ

Robert AllenNorth Bergen, NJ

Mary YoungNorth Bergen, NJ

Schedule An Appoinment

Welcome

Patient Information Confidential

Responsible Party

Insurance Information