Welcome Form Patient Information First Name Middle Initial Email (To Confirm Appointments) Phone (Primary) Phone (Secondary) May we text appointment reminders Last Name SSN Date of Birth Age Address City State Zip Employer Occupation Work Phone Emergency Contact Relationship Phone Parent/Legal Guardian Accompanying Minor First Name Middle Initial Last Name Relationship to Patient Phone (Primary) Phone (Secondary) SSN Date of Birth Employer Work Phone Address (If different) City State Zip Insurance Information Primary Dental Insurance Full Name of Insured Relationship to Patient Address (If different) City State Zip Insured's DoB SSN Employer Insurance Company Insurance Address Group # ID # Secondary Dental Insurance (Optional) Full Name of Insured Relationship to Patient Address (If different) City State Zip Insured's DoB SSN Employer Insurance Company Insurance Address Group # ID # Information Release (Optional) With the exception of your insurance and treating physicians, HIPAA restricts us from disclosing information to ANYONE without your written consent. If you wish to authorize release of information to someone (parent, spouse, friend etc...) please let us know: Name Relationship Name Relationship I authorize and request my insurance company to pay directly to the dentist otherwise payable by me. I understand that my dental insurance carrier may pay less then the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. You have my permission to contact me via cell phone to discuss any matters related to my account or that of my dependts. Signature of patient or responsible party (Type Full Name): Contact Us If you have questions or concerns, or wish to speak with one of our oral/maxillofacial specialists, then please contact our staff at Santa Rosa Oral Surgery, or set up an appointment by clicking here.