Marital Status MinorSingleMarriedDivorcedWidowedSeparated
Name of School/College
Full or Part Time Full TimePart Time
Patient’s or Parent’s Employer:
Spouse or Parent:
Whom may we thank for referring you?
Person to Contact in Case of an Emergency?
Name of Person Responsible for this Account
Relationship to Patient SelfParentGrandparentGuardianFamily memberRelativeOther
Drivers License #
Date of Birth
Social Security #
Is this Person Currently a Patient in our Office YesNo
Name of Insured
Relationship to Patient SelfParentGrandparentGuardianFamily memberOther
Union or Local #
Ins Company Address
Ins Company Phone
Do you have any additional Insurance YesNo
If YES, please complete the following
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE
I Agree *
To all of our valued patients,
Please see the letter in the link below about our upcoming reopening of our dental practice. We thank you for your patience during the COVID situation. We are doing everything we can to keep both our patients and staff protected as we move forward with continued dental care. We are excited to see all of you again! We have missed you! Our office will be reopening Monday, May 4, 2020. We will be contacting each of you to reschedule appointments that were moved in relation to COVID-19. Please don’t hesitate to call if you have any questions! Thank you!