New Patient Telephone Slip

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clientID

Location

Patient's Gender

M F

Patient Type*

Child Adult

Preferred Date & Time for Appointment

Patient's First Name*

Patient's Last Name*

Prefers to be Called:

Patient's Date of Birth*

Age:*

Address*

City*

State*

Zip Code*

Patient/Guardian Email:*

Phone*

Cell Phone #

Father/Partner Name (if minor):

Father Work Phone:

Father Cell Phone:

Mother/Partner Name (if minor):

Mother Work Phone:

Mother Cell Phone:

Responsible Party First Name*

Responsible Party Last Name*

Responsible Party DOB*

Responsible Party Relationship*

Contact Type*

Contact Info*

RMisc*

Financially Responsible

Do you have dental Insurance?

Yes No

Insured:

Insurance Co:

SSN:

DOB:

Telephone Number:

Member No:

Subscriber No:

Secondary Insurance:

Yes No

Insured:

Insurance Co.:

SSN:

DOB:

Member No:

Subscriber No:

Referral/Dentist

School (if student)

Any Allergies

Medications currently taking

IS THERE ANYONE ELSE IN THE FAMILY WHO WOULD LIKE TO BE SEEN AT THIS TIME?

Yes No

We ask this question because we are a family oriented practice. Many families have placed their confidence in our Doctor and Team. We have a family care program especially designed to serve your family. Each additional family member that begins treatment with our practice will receive a fee reduction.

Name:

DOB:

Date of Appointment made:

Day Date Time

We look forward to having you be a part of our orthodontic practice!

Please view our website.

Note