Name*

Name:

Phone*

Phone:

Email*

Email:

Best Time

Best Time:

Reason for Visit

Reason for Visit:

Email*

Email:

Registration Information for a Dependent

Patient Name:
^Last

^First

^MI

^{Preferred Name}

MaleFemale

Soc Sec #:

Birth Date:

Home Phone:

Cell Phone:

Home Address:
^Street

^City

^State

^Zip

Name of Parent or Guardian:
^Last

^First

^MI

MaleFemale

Emergency Contact Name and Phone:
^Name

^{Phone Number}

Other members of your immediate family who are patients in our office:

Who can we thank for referring you?

Responsible Party Information

Name:
^Last

^First

MaleFemale

Relationship to patient:

Address:
^Street

^City

^State

^Zip

Soc Sec #:

Birth Date:

Home Phone:

Cell Phone:

E-Mail Address:

Would you like text/email reminders?YesNo

Employer Name:

MarriedSingleOther

Work Phone Number:

Primary Insurance HolderSecondary Insurance Holder

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

Primary Insurance Policy

Name of Insured:

Is the insured a patient?YesNo

Insured's Date of Birth:

Insured's ID #:

Group #:

Insured's Employer:

Patient's relationship to the insured:
SelfSpouseChildOther

Dental Insurance Company Name:

Phone #:

Name of Insured:

Is the insured a patient?YesNo

Insured's Date of Birth:

Insured's ID #:

Group #:

Insured's Employer:

Patient's relationship to the insured:
SelfSpouseChildOther

Dental Insurance Company Name:

Phone #:

Registration Information for a Dependent

Patient Information

Last Name*

First Name*

Middle Initial

Preferred Name

Gender

Male

Female

Social Security #

Birth Date

Home Phone

Cell Phone

Street Address

City

State

Zip

Guardian Last name

Guardian First Name

Middle Initial

Gender

Male

Female

Emergency Contact Name

Emergency Contact Phone Number

Other members of your immediate family who are patients in our office

Who can we thank for referring you?

Responsible Party Information

Responsible Party Last Name

Responsible Party First Name

Responsible Party Gender

Male

Female

Relationship to patient

Street Address

City

State

Zip

Social Security #

Responsible Party Birth Date

Home Phone

Cell Phone

E-Mail Address

Would you like text/email reminders?

Yes

No

Employer Name

Marital Status

Married

Single

Other

Work Phone Number

Insurance Holder

Primary Insurance Holder

Secondary Insurance Holder

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

Name of Insured (Primary)

Is the insured a patient? (Primary)

Yes

No

Insured's Date of Birth (Primary)

Insured's ID # (Primary)

Group # (Primary)

Insured's Employer (Primary)

Patient's relationship to the insured (Primary)

Self

Spouse

Child

Other

Dental Insurance Company Name (Primary)

Phone # (Primary)

Name of Insured (Secondary)

Is the insured a patient? (Secondary)

Yes

No

Insured's Date of Birth (Secondary)

Insured's ID # (Secondary)

Group # (Secondary)

Insured's Employer (Secondary)

Patient's relationship to the insured (Secondary)

Self

Spouse

Child

Other

Dental Insurance Company Name (Secondary)

Phone # (Secondary)

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Contact

Scott W. Grant, DMD
2275 South Eagle Rd. Ste 140
Meridian, ID 83642

208.888.1195 phone
208.888.1571 fax

Copyright © 2010 Scott W. Grant, DMD