Name*

Name*

Name:
Phone*

Phone*

Phone:
Email*

Email*

Email:
Best Time

Best Time

Best Time:
Reason for Visit

Reason for Visit

Reason for Visit:
Email*

Email*

Email:

Registration Information

Patient Name:
Preferred Name:
Social Security #:
Birth Date:
Driver's License:
State:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Would you like text/email reminders?
Home Address:
Street

City

State

Zip
Employer Name:
Emergency Contact Name and Phone:
Please list other members of your immediate family who are patients in our office:

Referral Information

Can we thank someone for referring you?
Family Member
Coworker
Friend
Doctor
Or did you find us on your own?



We love referrals! When you refer a new patient to us we offer you a thank you gift of either movie tickets or a scented wax warmer.* Which would you prefer?
*(Does not include referrals of immediate family members.) *(By law, excludes Medicaid patients.)

Appointment Policy

We require 48 hours notice for appointment cancellations. Appointment changes without adequate notice may be subject to a fee of up to $50.00, payable by the patient and not the insurance company.

Insurance Information

Do you have insurance?YesNo

Primary Insurance Policy

Name of Insured:
Is the insured a patient?
Insured's Date of Birth:
Insured's ID #:
Group #
Insured's Employer:
Patient's relationship to the insured:
Dental Insurance Company Name:
Phone #:

Secondary Insurance Policy

Name of Insured:
Is the insured a patient?
Insured's Date of Birth:
Insured's ID #:
Group #
Insured's Employer:
Patient's relationship to the insured:
Dental Insurance Company Name:
Phone #:


New Patient Form



Registration Information

Registration Information



Patient Name*

Patient Name*

Preferred Name*

Preferred Name*

Gender

Gender



Marital Status

Marital Status




Social Security #

Social Security #

Birth Date

Birth Date

Driver's License Number

Driver's License Number

Driver's License State

Driver's License State

Home Phone*

Home Phone*

Work Phone

Work Phone

Cell Phone

Cell Phone

Email Address*

Email Address*

Text/Email Reminders

Text/Email Reminders



Street

Street

City

City

State

State

Zip

Zip

Employer Name

Employer Name

Emergency Contact Name and Phone

Emergency Contact Name and Phone

Family Member Patients

Family Member Patients

Please list other members of your immediate family who are patients in our office:



Referral Information

Referral Information



Can we thank someone for referring you?
Family Member

Family Member

Coworker

Coworker

Friend

Friend

Doctor

Doctor

Other Referral

Other Referral

Or did you find us on your own?



Referral Reward

Referral Reward






Insurance Information

Insurance Information



Do you have insurance?

Do you have insurance?



Name of Insured (Primary)

Name of Insured (Primary)

Is the insured a patient? (Primary)

Is the insured a patient? (Primary)



Insured's Date of Birth (Primary)

Insured's Date of Birth (Primary)

Insured's ID # (Primary)

Insured's ID # (Primary)

Group # (Primary)

Group # (Primary)

Insured's Employer (Primary)

Insured's Employer (Primary)

Patient's relationship to the insured (Primary)

Patient's relationship to the insured (Primary)




Dental Insurance Company Name (Primary)

Dental Insurance Company Name (Primary)

Phone # (Primary)

Phone # (Primary)

Name of Insured (Secondary)

Name of Insured (Secondary)

Is the insured a patient? (Secondary)

Is the insured a patient? (Secondary)



Insured's Date of Birth (Secondary)

Insured's Date of Birth (Secondary)

Insured's ID # (Secondary)

Insured's ID # (Secondary)

Group # (Secondary)

Group # (Secondary)

Insured's Employer (Secondary)

Insured's Employer (Secondary)

Patient's relationship to the insured (Secondary)

Patient's relationship to the insured (Secondary)




Dental Insurance Company Name (Secondary)

Dental Insurance Company Name (Secondary)

Phone # (Secondary)

Phone # (Secondary)

Copyright © 2010 Scott W. Grant, DMD