Patient And Responsible Party Information printable pdf download

Adult

Patient and Responsible Party Information

Patient Name____________________________________ Age_______ Sex______ Birth date________________

Address______________________________________________________________________________________

No. years at address______ Social Security #_________________________ Home Phone___________________

Fax #________________________ Cell #__________________________ Work #__________________________

Best number to call for appointments________ E-mail_______________________________________________

Whom may we thank for referring you to our office?________________________________________________

Marital Status:

Single

Married

Separated

Divorced

Widowed

Spouse’s Name______________________________________ Spouse’s Social Security #_____________________

Spouse’s Address________________________________________ Phone # _______________________________

Address (cont’d)________________________________________________________________________________

No. years at address________________ Occupation______________________ Position______________________

Employed By_________________________________________________ No. years employed there____________

Office Address__________________________________________________ Work Tel. #_____________________

Children

Birth date

______________________________________

___________________________

______________________________________

___________________________

______________________________________

__________________________

If responsible party is other than the patient or spouse, please give information

Not Applicable

Name_________________________________ Social Security #_______________Relationship________________

Address_______________________________________________________ Phone#_________________________

Medical History

Patient’s Family Dentist

Phone # ____________________________

Address_______________________________________________________________________________________

Patient’s Family Physician___________________________________ Phone # ____________________________

Address ______________________________________________________________________________________

Emergency Contact (person to contact in case of an emergency)

Name ________________________________ Phone #_______________________ Relation___________________

Patient And Responsible Party Information