NAME:

MARRIED  SINGLE  MINOR
MALE  FEMALE

MAILING ADDRESS:

CITY:STATE:

ZIP: 

BIRTHDATE: 

SS# 

STATE DRIVERS LICENSE # 

HOME PHONE: 

EMAIL ADDRESS: 

CELL PHONE: 

WORK PHONE: 

PLACE OF EMPLOYMENT(OR SCHOOL): 

DENTAL INSURANCE: 

PERSON RESPONSIBLE FOR ACCOUNT:
PATIENT FATHER(HUSBAND)   MOTHER(WIFE) GUARDIAN

PERSON TO CONTACT IN CASE OF EMERGENCY OUTSIDE OF IMMEDIATE FAMILY/HOUSEHOLD

NAME: 

ADDRESS: 

TELEPHONE: 

AUTHORIZATION I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DENTAL OFFICE OF THE GROUP INSURANCE BENEFTIS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL COSTS OF DENTAL TREATMENT. I HEREBY AUTHORIZE THE DENTAL OFFICE TO ADMINISTER SUCH MEDICATIONS AND PERFORM SUCH DIAGNOSTIC AND THERAPEUTIC PROCEDURES AS MAY BE NECESSARY FOR PROPER DENTAL CARE. THE INFORMATION ON THIS PAGE AND THE MEDICAL HISTORY ARE CORRECT TO THE BEST OF MY KNOWLEDGE.

SIGNATURE OF RESPONSIBLE PARTY:  
DATE: 

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