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Patient Information Form

 

The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

Patient Full Name *

Patient's Preferred Name:

Is the patient an insurance policy holder? *

Yes No  

Is the patient the responsible party? *

Yes No  

 

I. Responsible Party

Please fill out this section, if the responsible party is someone other than the patient. Otherwise, skip to section II.

 

Responsible Party Information: *

Same as Patient Create New Guarantor  

Guarantor First Name:

Guarantor Middle Name:

Guarantor Last Name:

Guarantor Mailing Address:

Guarantor City:

Guarantor State:

Guarantor Zip Code:

Guarantor Home Phone:

Guarantor Work Phone:

Guarantor Cell Phone:

Guarantor Email:

Guarantor Date of birth:

  

Responsible Party SSN:

Responsible Party Driver's License:

 

Is the Responsible Party also the insurance policy holder for the patient? *

Yes No  

If yes, please indicate whether primary or secondary insurance holder:

Primary Insurance Secondary Insurance  

 

II. Patient Information

Mailing address: *

City: *

State: *

Zip: *

 

Home phone: *

Work phone:

Cell phone:

 

Patient Gender: *

Male Female  

Patient Marital Status:

Single Married Divorced Widowed Other  

 

Birthdate:

  

SSN:

Driver's License: *

 

Patient Email: *

Preferred way to contact: *

Home phone Cell phone Email Work phone  

Dr. Frank Hsu may email confirmations, financial treatment plans, insurance information, and x-rays to myself or other dental providers:

Yes No  

 

Patient Employment Status:

N/A Full-Time Part-Time  

Student Status:

N/A Full-Time Part-Time  

Medicaid ID:

Employer ID:

Carrier ID:

 

III. Dental Insurance Information

Does the patient have dental insurance? *

Yes No  

 

Primary Insurance

Subscriber's Name:

Subscriber's Social Security #:

Subscriber's Birth Date:

Employer:

Insurance Company:

Insurance Company Phone #:

Insurance Company Address:

Group #:

ID #:

 

Secondary Insurance

Subscriber's Name:

Subscriber's Social Security #:

Subcriber's Birth Date:

Employer:

Insurance Company:

Insurance Company Phone #:

Insurance Company Address:

Group #:

ID #:

 

IV. Getting To Know You

What was the date of your last dental visit? *

Do you have any tooth related pain (sensitivity)? *

Yes No  

Do you have any jaw related pain (headache, migraine)? *

Yes No  

Do you clench or grind your teeth? *

Yes No  

Do you have frequent bad breath (Halitosis)? *

Yes No  

Do your gums bleed when you floss or brush? *

Yes No  

Do you have any breathing issues that might affect your sleep (ex. Snoring, Sleep Apnea)? If yes, please note which issues:

Did you have orthodontic treatment (braces)? *

Yes No  

 

Are you happy with your current smile?

Yes No  

Is there anything you would like to change about your smile?

Yes No  

If yes, what would you like to change?

 

How did you hear about our office?

Who may we thank for referring you to our office?

 
 
 

Signature and Confirmation

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 
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Frank Hsu, DDS
1553 Laurel St, Suite A,
San Carlos, CA 94070-5114
Phone: 650.262.1940
Fax: 650.592.1220
Email: frankhsu@sancarlosdental.com

Copyright © 2015-2017 Frank Hsu, DDS and WEO MEDIA. All rights reserved.  Sitemap | Links