Moore Family Dentistry-Patient Information

Patient Information Patient Details

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Thank you for visiting Moore Family Dentistry. We want your visit to be pleasant and comfortable. Please help us by completing this form.

First Name*

Last Name*

Middle Name

Nick Name

Date Of Birth*

Address*

City*

State*

Zip*

Employer

Gender*

Marital Status*

Social Security Number

Patient Information Contact Information

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Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

What is the best method to contact you?

May we email you an appointment reminder?

Yes
No

Patient Information Emergency Contact Information

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Emergency contact

Phone Number

Patient Information Primary Insurance Details

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Subscriber Name

Social Security #

DOB

Employer

Insurance Co. & State

Insurance Co. Phone #

Group #

Relation to patient

Please Specify

Not Filing with Insurance Self-Pay

Insurance Authorization Statement

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary or proper dental care. The information on this page and the medical history is correct to the best of my knowledge.

Patient Information Responsible Party's Information

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If Patient is Under 18

Responsible Party

Relation to Patient

Please Specify

Address

City

State

Zip

Phone Number

Patient Information Other Information

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How did you hear about us?

What is the reason for today’s visit?

Do you love your smile?

When was your last dental visit?

Why did you leave your last dentist?

What did you like most about your last dentist?

Do you require pre-medication prior to dental treatment?

Patient Information Authorization

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SIGNATURE (Signature)*

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Patient Information Patient Details

Patient Information Contact Information

Patient Information Emergency Contact Information

Patient Information Primary Insurance Details

Patient Information Responsible Party's Information

Patient Information Other Information

Patient Information Authorization

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