Sample New Patient Questionnaire

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PATIENT INFORMATION Patient Name: _____________________________________________________________ Date: ____________ Last, First, Middle Initial

Male

Preferred name

Female

Married

Birth Date:

Single

Child

Other ______________

Social Security #: ___________________________

Address: _____________________________________________________________________

_________ _

Apartment #, if any

House Number/Street Name

___________________________________________________ City

State

Phone (Home): ________________

(Work): ________________

Cell Phone: ___________________

__________

Zip Code

Ext: ______

_ Email Address: ___________________________ _______________

For Appointment Reminders via text

For Appointment Reminders and dental records as needed

Emergency Contact Person: Name: ________________________

_____

Relationship to Patient: __________________________

Immediate Contact Phone Number: ______________________________

Responsible Party Information IF DIFFERENT FROM ABOVE

Name: Male

Female

Relationship to above patient:

Self

Birth Date:

Spouse

Parent

Other

Social Security #:

IF THE FOLLOWING IS SAME AS ABOVE, CHECK HERE:



Address: _____________________________________________________________________

_________ _

House Number/Street Name

Apartment #, if any

___________________________________________________________ City

State

Zip Code

Best Contact Number (regarding account if needed) ________________

Best time to call:

_____________

Insurance Information Primary Coverage

Name of Insured: Male

Female

Relationship to above patient:

Birth Date:

Self

Spouse

Parent

Other

Insurance I.D.# or Social Security #:

IF THE FOLLOWING IS SAME AS ABOVE, CHECK HERE:



Address: _____________________________________________________________________ House Number/Street Name

_________ _ Apartment #, if any

___________________________________________________________ City

State

Zip Code

Phone (Home): ________________ (Work): ________________ Ext: ______ Cell Phone: ___________________

Best time to call: _____________

_ Email Address: ___________________________

Insured's Employer Group Name:

_______________

Group #:

Insured’s Dental Insurance Company Name/Phone #: IF SECONDARY COVERAGE EXIST, PLEASE CHECK HERE:  Please present insurance card to front desk for a copy and additional information as needed to process Secondary Coverage.

576 North Sunrise Boulevard * Suite 140 * Roseville * California * 95661 * 916-786-6431 6600 Mercy Court * Suite 230 * Fair Oaks * California * 95628 * 916-966-4620