New Patient Consultation Information Form

1. Patient Name *

First

Last

2. Patient Date of Birth *

3. Name of the patient's General Dentist

4. Parent Name (If patient is a minor)

First

Last

5. Contact Email *

6. Contact Phone Number. Please also specify your cell phone provider if you would like text appointment reminders.

7. Contact Address

8. Financially Responsible Party *

Same as Parent above. Skip to #13
Same as Patient above. Skip to #13
Other. Please fill out the information below

9. Name of person financially responsible

First

Last

10. Email of person financially responsible

11. Phone Number of Person Financially Responsible

12. Address of person financially responsible

13. Is the patient covered under a dental insurance policy?

Yes
No, skip down to #18

14. Name of Dental Insurance Company

15. Name of Policy Holder

First

Last

Policy of Address

16. Date of Birth of Policy Holder

17. Member ID# or SSN of Policy Holder

18. Preferred Method of Contact

Phone
Email

19. How did you hear about our office?

20. Please provide any additional information or areas of concern. Also, if the patient is covered by an additional dental insurance policy, please provide the name of policy holder, their date of birth, insurance name and member ID# here.