Patient Information Questionnaire
 

 
1. Patient Information
Who referred you to our office?:
First Name:       MI: 
Last Name: 
Social Security #  - -
Male     Female
Birth date:  - -
Home Address: 
City:    State:  
Zip: 
Home Phone Number:   - -
Cell Phone Number:       - -
Work Phone Number:   - -
Employer: 
Employer Address: 
How long there?    
 Occupation: 
When are best times to reach you? 
2. Spouse Information
Social Security #  - -
His / Her Name: 
Employer: 
Work Number:  - - Ext. 
Billing Address:  
3. Insurance Information
Primary:
Employee Name: 
Responsible Party's Employer:
Insurance Co. Name: 
Insurance Co. Address:  
Group/Policy #
Employee SSN:  - -
Birth date:  - -
Annual Deductible: 
Maximum Annual Benefit:
In the event of an emergency, is there something
who lives near you that we should contact?
His / Her Name:  
Relation: 
Work Number:   - -        Ext. 
Home Number:  - -    
AGREEMENT:  I hereby authorize my insurance benefits to be paid directly to the dentist.  I am financially responsible for any balances due.  I also authorize the dentist to release any information required for claims.  In consideration for the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policies. 

I also authorize that my records may be used by the dentist if he so determines, and may be shared or discussed with other medical/dental professionals to whom I have been referred, or by whom I am seeking treatment. 

I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations.  I understand that my photos or x-rays will be rendered "anonymous" before being displayed, unless I provide specific, written authorization for head or face photos to be used.

I certify that I have read or have had read to me, the contents of this form.

I Agree    I don't agree