PatientInfo adult.pages

The benefits of a happy, healthy smile
are immeasurable! The information you
provide is important for a thorough
evaluation, and needs to be updated as
changes occur.
Adult Patient Information
Name
Birthdate
Sex
Age
Address
Physician
Dentist
Emergency contact
Whom may we thank for referring you?
Other family members seen at our office
Email for appointment confirmations
Preferred Name
Contact #
City/State/Zip
Phone #
Phone #
Phone #
Employment Information
Occupation
Employer
Business Address
Work #
How long at current job?
Social Security #
If another person will be helping with this account, please provide his/her information below
Name
Contact #
Relationship to patient
Occupation
Work #
Social Security #
Employer
How long at current job?
Business Address
Insurance Information
Primary Insurance Company
Address
Group #
Phone #
Subscriber
Birthdate of Subscriber
SS# or ID #
Secondary Insurance Company
Address
Group #
Phone #
Subscriber
Birthdate of Subscriber
SS# or ID#
I understand that credit bureau reports may be obtained. If necessary, I authorize Shaw Orthodontics to access my records from other
caregivers. I acknowledge that I am responsible for all charges incurred regardless of insurance benefits or prearranged parent/
guardian agreements.
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Signature!
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Relationship to patient!!
Date