Patient Information Form

 

Please complete all of questions to the best of your ability. The better we communicate, the better we can care for you. Questions are welcome and appreciated.

 

About You

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Nick Name:

Date of birth: *

  

 

Age:

 

SSN:

 

Gender: *

  Male   Female  

 

Home phone:
(###-###-####) *

 

Work phone:
(###-###-####)

 

Cell phone:
(###-###-####)

 

Driver Lic. #:

 

Patient Email: *

Preferred way to contact: *

Home phone Cell phone Email Work phone  

Patient Marital Status:

Single Married Separated Divorced Widowed  

Home Address: *

City: *

State: *

 

Zip: *

 

Employer

Employer Name:

Employer Address:

How long there?

 

Occupation:

 

When & where are the best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

Previous/Present Dentist:

Last Visit Date:

 
 

Spouse Information

Spouse Name:

Spouse Employer:

Work Number:
(###-###-####)

 

SS#:

 

Driver Lic. #:

 

Date of Birth:

  

 

Person Responsible for Account: *

Billing Address:

Work Number:
(###-###-####)

 

Home Number:
(###-###-####)

 

Relationship:

 

SSN:

 

Employer:

 

Driver Lic. #:

 

 
 
 

 

Primary Insurance

Dental Coverage? *

Yes No  

Insurance Co. Name:

 

Insurance Co. Address:

 

Insurance Co Phone:
(###-###-####)

 

Group or Policy#:

 

Insured's Name:

 

Relation:

 

Insured's Birth Date:

 

Insured's ID:

 

Insured's Employer:

Employer's Address:

 

Secondary Insurance

Dental Coverage? *

Yes No  

Insurance Co. Name:

 

Insurance Co. Address:

 

Insurance Co Phone:
(###-###-####)

 

Group or Policy#:

 

Insured's Name:

 

Relation:

 

Insured's Birth Date:

 

Insured's ID:

 

 

Insured's Employer:

Employer's Address:

 

Please, bring insurance card(s) for dental coverage to your visit.

 

Neighbor or Relative not living with you (for emergency)

Name:

 

Relation:

 

Work Number:
(###-###-####)

 

Home Number:
(###-###-####)

 

Address:

City:

State:

 

Zip Code:

 

 
 

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OHIOSmiles

1500 Deerpath Drive
Cambridge, OH 43725

(740) 630-9797

Opening Hours

Monday & Tuesday: 8am–4pm
Wednesday: 11am–7pm
Thursday: 8am–4pm
Friday: 7am–3pm

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