WELCOME We are pleased to welcome you to our practice.

Please complete this form, and provide any insurance cards.

PATIENT INFORMATION

Name ------------------------------------- Soc. Sec.# ________ _ Address ______________________________________________________________ _

City ______________ _ State ___ _ Zip ____ _ Cell Phone ____________________ _ Home Phone ---------------------------

Birthdate Email _______________________ __ -----------------------------Single_ Married __ Widowed __ Separated __ Divorced __ Em pi oyer Occupation ______________________ _ Notify in case of emergency Relationship _________ _ Phone Number __________________________ ___

PRIMARY DENTAL INSURANCE

Subscriber Name __________________________ ___ Birthdate __________ _ Employer ________________________________ __ Soc. Sec.# ________ _

Insurance Company ________________________ _ Phone Number _____________ _ Insurance Company Address _______________________________________________ _ City_________ State ______ _ Zip ____________ _

ID Number _________________ _ Group Number ________________ _

SECONDARY DENTAL INSURANCE

Subscriber Name __________________________ ___ Birth date _________ _ Employer ________________________________ __ Soc. Sec.# ________ _ Insurance Company ________________________ _ Phone Number ---------------I nsu ranee Company Address ______________________________________________ _ City ________ _ State ______ _ Zip ______ _

ID Number -------------------Group Number _______________ _

I authorize the dentist to release all information necessary to secure payment of insurance benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature __________________________ _ Date ___________________ _

Print Name -----------------------------