Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Birthday:
Gender:
Male
Female
Other
Patient’s Dentist - (If no current dentist, write none)
Last Dental Visit
School (if applicable):
Medical History
Have there been any changes to the patient’s health history? If yes, please explain. If no, please write none.
Please list any medications currently being taken by the patients, including non-prescription:
Responsible Parties
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Birthday:
Gender:
Male
Female
Other
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address:
City:
State:
Zip:
Phone#:
Email:
Preferred Method of Communication
Call
Text
Email
No Preference
Responsible Party #2
First Name:
Last Name:
Birthday:
Gender:
Male
Female
Other
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address:
City:
State:
Zip:
Phone#:
Email:
Preferred Method of Communication
Call
Text
Email
No Preference
Insurance Information
Check if the responsible party is the same as the insurance policy holder.
Do you have dental insurance?
No
Yes
Does it cover orthodontics?
No
Yes
Primary Insurance
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Policy Holder's Birthdate:
Gender:
Male
Female
Other
Policy Holder's Employer:
Subscriber ID:
Group Number:
Social Security #:
Do you have secondary insurance? If so, please fill in information below.
No
Yes
Secondary Insurance
Check if the responsible party is the same as the secondary insurance policy holder.
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Name:
Policy Holder's Birthdate:
Gender:
Male
Female
Other
Policy Holder's Employer:
Subscriber ID:
Group Number:
Social Security #:
Patient's E-Signature:
Patient's Personal Representative's E-Signature:
Relationship to patient:
Self
Parent
Guardian
Other
If Other: