Text 6

Patient Information


	Full Patient Name:


	Date of Appointment:


	PT#:


	Social Security Number:


	Email Address:


	Contact Phone Number:


	Address:


	City, State & Zip:


	Sex:


	Male


	Female


	Age:


	DOB:


	Single


	Married


	Widowed


	Separated

Divorced


	Employed by:


	Occupation:


	Full Business Address:


	Business Phone Number:


	How did you hear of us:


	Emergency Contact:


	Contact Phone Number:




	Primary Insurance


	Name on Account:


	Relationship to Patient:


	Birthdate:


	Social Security Number:


	Full Address:


	Phone Number:


	Employed by:


	Occupation:


	Full Business Address:


	Business Phone Number:


	Insurance Company:


	Contract Number:


	Group Number:


	Subscriber Number:


	Name of Dependants:




	Additional Insurance


	Is the patient covered by additional insurance:


	Yes


	No


	Name on Account:


	Relationship to Patient:


	Birthdate:


	Social Security Number:


	Full Address:


	Phone Number:


	Employed by:


	Occupation:


	Full Business Address:


	Business Phone Number:


	Insurance Company:


	Contract Number:


	Group Number:


	Subscriber Number:


	Name of Dependants:




	Authorization

	I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.