Patient Registration and Medical History

Smithsburg Family Dentistry

Thomas M. Nussear, DDS
Comprehensive Dentistry
40 South Main Street ⸱ Smithsburg, MD 21783
301-824-2080

WELCOME!

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us-we will be happy to help.
PATIENT INFORMATION
Check Appropriate Box:*

MinorSingleMarriedDivorcedWidowedSeparated
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Social Security No.*
Driver's License No.
Address*

Address

Street Address Line 2

CityState

Zip
Home Phone
Work Phone
Cell Phone
Email Address*
example@example.com
Whom may we thank for referring you?
Person to contact in case of emergency*
Emergency Contact Phone*

EMPLOYMENT/SCHOOL
Patient's Employer/School
Address

Address

Street Address Line 2

CityState

Zip
Patient's (if minor)/Spouse's Name
Home Phone
Patient's/Spouse's Employer
Work Phone
Address

Address

Street Address Line 2

CityState

Zip

RESPONSIBLE PARTY
Person Responsible for this Account*
Name
Relationship to Patient*
Birth Date*

MonthDayYear
Date
Driver's License No.
Address*

Address

Street Address Line 2

CityState

Zip
Home Phone*
Work Phone
Employer
Is this person currently a patient in our Office?*

YesNo

INSURANCE INFORMATION
Name of Insured
Relationship to Patient
Birthdate

MonthDayYear
Date
Social Security No.
Date Employed

MonthDayYear
Date
Employer
Work Phone
Address

Address

Street Address Line 2

CityState

Zip
Insurance Company
Group No.
Carrier ID
Address

Address

Street Address Line 2

CityState

Zip
How much is your deductible?
How much have you used?
Maximum Annual Benefit
DO YOU HAVE ANY ADDITIONAL INSURANCE?*

YesNo

IF YES, COMPLETE THE FOLLOWING (click to expand)
Name of Insured
Relationship to Patient
Birthdate

MonthDayYear
Date
Social Security No.
Date Employed

MonthDayYear
Date
Employer
Work Phone
Address

Address

Street Address Line 2

CityState

Zip
Insurance Company
Group No.
Carrier ID
Address

Address

Street Address Line 2

CityState

Zip
How much is your deductiblel
How much have you usedit
Maximum Annual Benefit