Patient is: Policy Holder
Responsible Party (if someone other than the patient):
Work Phone: Ext:
Responsible Party is also a Policy Holder for Patient
| Marital Status:
I would like to receive correspondence via email.
I would like to receive appointment reminders via text messages sent to my mobile phone.
I was referred by:
Emergency Contact #:
Dental Insurance Information:
Name of Insured:
Relationship to Insured:
Insured Social Security:
Insured Birth Date:
City, St, Zip:
Contract# / Member ID:
Customer Service #:
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT*
I acknowledge that I have received a copy of this office's Notice of Privacy Practices.
Patient Signature: Enter Name: