Welcome Form

Patient Information

First Name

Middle Initial

Email (To Confirm Appointments)

Phone (Primary)

Phone (Secondary)

Phone Carrier (Appt 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):

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.