Patient Information

Date:

Age:

Sex:

Male

Female

Patient Name:

Last Name:

Address:

City:

State:

Zip:

Home Phone:

Birthdate:

Social Security #

If patient is a minor, give parent's or guardian's name:

Whom may we thank for referring you to our office?

Who is your general dentist?

Email:

Responsible Party Information

Name:

Marital Status:

Residence:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

How long at this address:

Home Phone:

Work Phone:

Previous Address (if less than 3 yrs.)

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:

Insurance Information

Insured’s Name:

Birthdate:

Social Security #

Insurance Company:

Group No.

Local No.

Ins. Co. Address:

Ins. Phone No.

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO GILBERT H. SNOW, D.D.S. OF THE GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME.

(Signed Insured Person)

(Date)

Coverage: %

Eff. Date:

Eligibility:

Remarks:

Do you have dual coverage?

Yes

No

Emergency Information

Name of nearest relative not living with you:

Phone:

Complete Address:

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

Signature (Parent's signature if minor)

Updates (date & initial)

It is your obligation to inform us of any health changes.

Signature (of parent, if minor)

Date:

Initials: