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Patient Information

Date Today

Date of Birth _____|____|____AGE__________MALE [ ]  FEMALE  [ ] HOME PHONE (   )____________

ADDRESS_____________________________________________APT____CITY, STATE & ZIP

SOCIAL SECURITY # _________|_____|__________ EMPLOYER__________________________________

EMPLOYER ADDRESS____________________________________CITY, STATE, & ZIP_________________________________

FULL TIME STUDENT?    YES [ ]    NO [ ]                 NAME OF SCHOOL_______________WHAT  CITY?_________________________

REFERRED BY____________________________DENTIST_________________________________________________

OTHER DENTAL SPECIALIST (i.e., Orthodontist, Periodontist)_________________________________________

PHYSICIAN (MEDICAL DOCTOR)________________________________________________________

HAVING PAIN NOW?   YES [ ]    NO [ ]    ARE WE SEEING YOU TODAY FOR CONSULTATION   [ ] EXTRACTION   [ ] JAW PROBLEM [ ] INJURY [ ] IF INJURY - EXPLAIN: ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

FAMILY INFORMATION (HEAD OF HOUSEHOLD, FINANCIALLY RESPONSIBLE PARTY)

NAME OF PARENT_________________________________________

DATE OF BIRTH _____|____|_____

ADDRESS_______________________________________________

APT______CITY, STATE & ZIP______________________

(IF NOT SAME AS PATIENT)

HOME PHONE (    )___________BUSINESS PHONE (   )____________

SOCIAL SECURITY #______________________________

EMPLOYER'S ADDRESS_____________________________________________________CITY, STATE & ZIP______________________

MARITAL STATUS:     [ ] SINGLE        [ ] MARRIED      [ ] SEPARATED      [ ] DIVORCED      [ ] WIDOWED

SPOUSE'S NAME___________________________________________DATE OF BIRTH______|_____|_______

ADDRESS______________________________________________________APT______CITY, STATE & ZIP_______________________

HOME PHONE (     ) _______________BUSINESS PHONE (    )________________________SOCIAL SECURITY #____________________

EMPLOYER'S ADDRESS____________________________________________________CITY, STATE & ZIP________________________

HAS ANY MEMBER OF YOUR FAMILY BEEN A PATIENT HERE BEFORE?  YES [ ]  NO [ ]

IF YES, WHOM?__________________________________________________RELATIONSHIP TO YOU____________________________

NEAREST RELATIVE OR FRIEND NOT AT SAME ADDRESS:

NAME________________________________________________TELEPHONE (    ) ___________________________________________

ADDRESS_____________________________________________CITY, STATE & ZIP__________________________________________

______________________________________________________

SIGNATURE OF PARENT COMPLETING THIS FORM.

**THIS PATIENT IS UNDER 18 YEARS OLD, OR THE PARENTS HAVE AGREED TO BE RESPONSIBLE.

(DATA ENTRY BY:_______________________)