PATIENT INFORMATION FORM

FORM #1 --- Please compete these forms, and bring them with you for your first appointment. It will save you several minutes! Thank You, Dr. Waldrop and staff. Patient's Full Name: ___________________________________Date:________________ Patient's Sex _______ Patient's Occupation ____________________________________ If Patient a Full Time student - name of school __________________________________ Patient's Marital Status: Married [ ] Single [ ] Divorced [ ] Widowed [ ] Patient's Date of Birth: ___________________ Patient's Social Security Number: ____________________________________________ Patient's Address: _________________________________________________________ City: _________________________ State: ________ Zip Code: _____________________ Home Phone: _____________________ Work Phone: ____________________________ Name of Employer:____________________ Address: ____________________________ City:_________________________________ State:________ Zip Code: ______________ In case of Emergency, who should be notified:__________________________________ Phone:________________ Relationship to Patient:_______________________________ Whom should we thank for referring you?_______________________________________ Person Responsible for this account:__________________________________________ Billing address if different from Patient Address:_________________________________ ____________________ City:_________________________ State:____ Zip:___________ Spouse's Full Name: _______________________________________________________ Spouse's Occupation: ______________________________________________________ Work Phone: ___________________ If patient is a child-------- Patient's Father:___________________________________________________________ Father's Address:__________________________________________________________ Father's Occupation:_______________________________________________________ Home Address:____________________________________________________________ City:________________________________ State:_________ Zip:___________________ Work Address: ____________________________________________________________ City: _______________________________State:__________Zip:____________________ Home Phone:_________________________ Work Phone:_________________________ Patient's Mother: __________________________________________________________ Mother's Address if different from above: _________________________________________________________________________ City: ______________________________State: __________Zip:____________________ Work Address: ____________________________________________________________ City: ____________________________________State:___________Zip:______________ Home Phone:__________________________Work Phone:________________________ -----------------------------------Primary Insurance------------------------------------ Policy Holder:_____________________________________________________________ Relationship to Patient: _____________________________________________________ Date of Birth:______________________________________________________________ Address [if different from patient]______________________________________________ City:___________________________________State:________Zip:__________________ Policy Holder Employed by:__________________________________________________ Social Security Number:_____________________________________________________ Policy Holder's Driver's License No:___________________________________________ Insurance Company:________________________________________________________ Group Number:___________ Subscriber Number:_________________________________ Insurance Company Address:________________________________________________ City:___________________________________ State:_____________Zip:_____________ Insurance Company Phone:__________________________________________________ Work Benefits Office Number:_________________________________________________ -----------------------------------Secondary Insurance------------------------------------ Policy Holder:_____________________________________________________________ Relationship to Patient: _____________________________________________________ Date of Birth:______________________________________________________________ Address [if different from patient]______________________________________________ City:___________________________________State:________Zip:__________________ Policy Holder Employed by:__________________________________________________ Social Security Number:_____________________________________________________ Insurance Company:________________________________________________________ Group Number:___________ Subscriber Number:_________________________________ Insurance Company Address:________________________________________________ City:___________________________________ State:_____________Zip:_____________ Insurance Company Phone:__________________________________________________ Work Benefits Office Number:_________________________________________________ Where a third party is involved, I authorize H.L. Waldrop, D.D.S. to be paid directly. I certify that I have provided the above information for the collection of debts incurred in my dental treatment and I certify that my questions concerning cost and treatment have been answered to my satisfaction. _______________________________________ Signature of Patient or Personal Representative _______________________________________ Name of Patient or Personal Representative [Please Print] _______________________________________ Date ____________________________________________________________ Descripton of Personal Representative's Authority. © 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.