PATIENT INFORMATION FORM

CONFIDENTIAL INFORMATION QUESTIONNAIRE

PATIENT’S LEGAL NAME (Last, First, Middle) (required)
Your Email (required)
DATE OF BIRTH
SEX
SOCIAL SECURITY #
PREFER TO BE CALLED
HOME PHONE #
CELL PHONE #
PATIENT’S ADDRESS NUMBER
STREET
APT#
CITY
STATE
ZIP
MARITAL STATUS SMWDUNDER AGE 18
PATIENT’S / GUARDIAN’S EMPLOYER
OCCUPATION
WORK ADDRESS NUMBER
STREET
APT#
CITY
STATE
ZIP
WORK PHONE #
SPOUSE’S NAME (Last, First, Middle)
SPOUSE’S WORK ADDRESS NUMBER
STREET
APT#
CITY
STATE
ZIP
SPOUSE’S EMPLOYER
OCCUPATION
WORK PHONE #
OTHER FAMILY MEMBERS THAT ARE PATIENTS HERE
WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE?

EMERGENCY CONTACT INFORMATION

PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)

NAME
RELATIONSHIP
HOME PHONE #
WORK PHONE #
CELL PHONE #

REQUEST FOR CONFIDENTIAL COMMUNICATION
AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION:
Contact me at home yesno
Contact me via cell phone yesno
Contact me at work yesno
Contact me via e-mail yesno
Leave messages on my home voicemail / answering machine yesno
Leave messages on my cell phone voicemailyesno
Leave messages on my work voicemail / answering machine yesno