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Patient Forms - Patient Info Sheet  

Our goal is to help you reach and maintain maximum oral health. Please fill out the form completely. The better we communicate, the better we can care for you. Thank you and we are glad you are here!

If you would prefer to print out the form and bring it with you, click on the link below. Otherwise an online form has been provided below. Thank you for answering the following questions.

Patient Info Form (pdf)

About Child

Today's Date: Patient's Name:
  LastFirstMI
Date of Birth: - -Age: Preferred Name: Male  Female
 MonthDayYear      
How did you hear about our office? 

Mother's Information

Use as primary contact information for patient    Yes  No
Name:   Phone (h) ( 
first and last
 
Address:  (w) ( 
City:  State:  Zip:  (c) ( 
DOB: --  SSN: -- Can we text appointment information to your cell phone:  Y  N
Email Address: 

Father's Information

Use as primary contact information for patient    Yes  No
Name:   Phone (h) ( 
first and last
 
Address:  (w) ( 
City:  State:  Zip:  (c) ( 
DOB: --  SSN: -- Can we text appointment information to your cell phone:  Y  N
Email Address: 

Dental Insurance Information

Name of Employee: Employee's
Date of Birth:
- -
Employer Name: Employee's ID# or SSN:
Insurance Co. Name: Group #:
Insurance Co. Address: Phone # for customer service:() -
City:  State:  Zip:  

Dental History

Why has your child come to the dentist today? 
How long since their last dental visit? 
Name of previous dentist? 
Has patient had orthodontic treatment in the past?  Yes  No
Do they currently wear any retainers or night guards?  Yes  No

 
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