Confidential Patient Information – I
(Please Print Legibly)
DATE:
PERSONAL INFORMATION
Name:	SS#:
Address:
City:	State: Zip:
Telephone: (Home):	(Work)
(Cell)	e-mail:
Birth date: Sex: Marital Status: Spouse Name:
Occupation:	Referred by:
PERSON RESPONSIBLE FOR ACCOUNT
Name:	Relationship: SS#:
Address:
City:	State: Zip:
Telephone: (Home):	(Work)
DENTAL INSURANCE INFORMATION
Primary Insurance Co:
Insurance Co. Address:
Employee: Relationship: S.S. #:
Employer:	Policy #:
Secondary Insurance Co:
Insurance Co. Address:
Employee: Relationship: S.S. #:
Employer:	Policy #:
I understand that payment is my obligation regardless of insurance or any other third-party involvement.
SIGNATURE: DATE: