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Peysernewpatientmedicalform

following questions so we can better assist you with your dental needs.
PATIENT INFORMATION
Today’s Date__________________________ Birth Date__________________________ Patient Social Security #____________________________________________
Patient Name_______________________________________________________________________________________________________________________________ Street Address_______________________________________________________________________________________________________________________________ City_________________________________________________________________ State_______________________________ Zip_______________________________ Occupation____________________________________________ ❑ Male ❑ Female ❑ Single ❑ Married ❑ Widowed ❑ Divorced ❑ Separated Patient Home Phone______________________________________________________ Patient Work Phone________________________________________________ Employer________________________________________________________________ Employer Phone___________________________________________________ Employer Address___________________________________________________________________________________________________________________________
In Case of Emergency Contact:
Name______________________________________________________________________________________ Relationship_____________________________________
Emergency Home Phone__________________________________________________ Emergency Work Phone_____________________________________________
Whom may we may we thank for referring you to us?_________________________________________________________________________________________
PRIMARY INSURANCE
Individual responsible for this account_________________________________________________________________________________________________________
Relationship to Patient______________________________________ Birth Date_________________________ Social Security #_______________________________ Street Address___________________________________________________________________________ Home Phone_______________________________________ City_________________________________________________________________ State_______________________________ Zip_______________________________ Responsible Party Employed By____________________________________________________________ Business Phone___________________________________ Business Address_________________________________________________________________________ Occupation_______________________________________ Insurance Company__________________________________________________________________________________________________________________________ Insurance Company Address__________________________________________________________________________________________________________________ Subscriber I.D. #__________________________________________________________ Group #__________________________________________________________ ADDITIONAL INSURANCE
Insured Individual’s Name____________________________________________________________________________________________________________________
Relationship to Patient______________________________________ Birth Date_________________________ Social Security #_______________________________ Street Address___________________________________________________________________________ Home Phone_______________________________________ City_________________________________________________________________ State_______________________________ Zip_______________________________ Insured Party Employed By________________________________________________________________ Business Phone____________________________________ Insurance Company__________________________________________________________________________________________________________________________ Insurance Company Address__________________________________________________________________________________________________________________ Subscriber I.D. #__________________________________________________________ Group #__________________________________________________________ ASSIGNMENT AND RELEASE
I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the
use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature_____________________________________________________________________________________________________ Date_________________________ Payment is due in full at time of treatment unless prior arrangements have been approved.
family HealtH information
some health conditions are the result of hereditary weaknesses. information that you can furnish us pertaining to your immediate family members

(brothers, sisters, parents and grandparents) will give us a better understanding of your health needs.
Family Members Present and Past Health Problems mediCations
allergies
List medications you are currently taking: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Pharmacy____________________________ Phone_____________________ CHeCk any symPtom(s) or Condition(s) BeloW tHat you Currently Have or Have Had in tHe Past year:
CHeCk degree of HaBits BeloW. all information Will Be kePt striCtly Confidential.

I certify that the above information is correct to the best of my knowledge. I will not hold my dentist or any members of his/her staff responsible for any er- rors or omissions that I may have made in the completion of this form.
Signature________________________________________________________________________________________ Date______________________________________

Source: http://www.manhattandentist.info/images/PeyserNewPatientMedicalForm.pdf

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