Page 1 | O'Neal Smiles | Patient Information

Patient Information Title:
First Name: Last Name: MI:
I prefer to be called: Gender: Male Female
Birthdate: Social Sec.#: Driver's Lic.#:
Address: Address 2:
City: State: Zip:
Home Phone: Cell: Work:
Email: Employer:
Whom may we thank for referring you?
Physician Name: Physician Phone:
Pharmacy Name: Pharmacy Phone:
Emergency Contact: Emergency Phone:

Person Responsible for Account (if other than Patient) Name: Relationship:
Birthdate: Social Sec.#: Driver's Lic.#:
Address: Address 2:
City: State: Zip:
Home Phone: Cell:
Work: Email:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

** You may refuse to Sign this Acknowledgement**

I, the undersigned, certify that I have read, understand, and agree to abide by the above policies.

I have received a copy or have been given access to the O'Neal Smiles, LLC Notice of Privacy Practices. I give my permission to O'Neal Smiles, LLC to:

Communicate with other health care professionals and dental insurance carriers (if applicable) as needed throughout the course of my care.
Leave messages for me at my contact numbers provided and mail or email reminders to me regarding appointment dates and times.

Signature of Patient or Responsible Party: Date: