K & K Dental Studio Patient Information

Patient Information

Welcome to our Dental Office!
Date:*

MonthDayYear
The information that is requested on the Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are commited to collecting, using and disclosing this information responsibly.

This information will enable us to maintain communication with you.
The patient is an:*

AdultChildUnder Guardianship
If Under Guardianship, please list name:

First NameLast Name
Patient Name:*

First NameLast Name
Please select:*

Mr.Mrs.Dr.Miss
Prefers to be called:*
Language preference:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone number:*
Please enter a valid phone number.
Cell phone number
Please enter a valid phone number.
Work phone number:
Please enter a valid phone number.
Work extension:
Employer:
May we call you at work:

YesNo
Email*
example@example.com
Date of birth:*

MonthDayYear
Date
Age:*
Gender:*

MaleFemale
Marital Status:*

SingleMarriedDivorcedOther
Name of spouse:

First NameLast Name
Preferred appointment time:*
Whom may we thank for referring you?*
Are other family members patients at our office? If yes, please list their names:
Medical Priority

This information will enable us to make any essential contacts.
Family Physician:*

First NameLast Name
Physician phone number:*
Please enter a valid phone number.
Medical Specialist (if presently under care):

First NameLast Name
Specialist phone number:
Please enter a valid phone number.
In case of emergency, please contact:*

First NameLast Name
Contact phone number:*
Please enter a valid phone number.
Nearest relative not living with you:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Reason for today's visit:*

ExaminationEmergencyOther
Is there a dental problem you would like treated immediately?
Financial Information

This information is necessary to process invoices and apply payments. Please complete all information only if different than above.
Person responsible for account:*

SelfSpouseOther
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name:
Employer Phone:
Please enter a valid phone number.
Method of payment:*

CashChequeCredit CardOther
Primary Dental Insurance

Complete information only if required by office
Subscriber's Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Employee / Group policy number:
Insurance year end:

MonthDayYear
Date
Insurance company name:
Phone number:
Please enter a valid phone number.
Group / Individual policy number:
Certificate number:
ID Number:
Maximum coverage:
Please list percentage of coverage for Basic, Major Restorative, Ortho and Other
Please upload a copy of your insurance card, front and back:

Cancelof
Secondary Dental Insurance

Complete information only if required by office
Subscriber's Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Employee / Group policy number:
Insurance year end:

MonthDayYear
Date
Insurance company name:
Phone number:
Please enter a valid phone number.
Group / Individual policy number:
Certificate number:
ID Number:
Maximum coverage:
Please list percentage of coverage for Basic, Major Restorative, Ortho and Other
Please upload a copy of your insurance card, front and back:

Cancelof
Patient Signature:*

Clear
Use your mouse to sign by holding down the button continuously with your index finger and signing/moving the mouse in the signature box.
Date*

MonthDayYear
Should be Empty:

Patient Information

Medical Priority

Financial Information

Primary Dental Insurance

Secondary Dental Insurance