• Hillsboro: (503) 642-1535 • Portland (Cedar Hills): (503) 644-4749

Patient Information Form

 

The information provided on this form is important to your children's 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.

 

Contact Information

Preferred Hi5 Dental Location:

Cedar Hills Hillsboro  

 

How did you hear about us?:

Yelp
Google
Insurance Provider
Family/Friend

If Family/Friend, their name:

 

Patient Name 1: *

Patient Name 2:

Patient Name 3:

Emergency Contact (Please list contact other than parent/guardian): *

Relation to patient?: *

Home phone: *

 

Parent/Guardian Information

Parent Name 1: *

Relation to Patient: *

Date of birth: *

  

Home phone: *

Work phone:

Cell phone:

Email: *

 

Mailing address: *

City: *

State: *

Zip: *

Employer:

Occupation:

Preferred way to contact: *

Home phone Cell phone Email Work phone  

 

Parent Name 2:

Relation to Patient:

Date of birth:

  

Home Phone:

Work Phone:

Cell Phone:

Email:

 

Mailing Address:

City:

State:

Zip:

Employer:

Occupation:

Preferred method of contact:

Home phone Cell phone Email Work phone  

 

Patient Insurance Information

Primary Insurance Provider:
(Bring copy of card to appointment)

Insurance Phone Number:

Subscriber (Legal Name):

Date of birth:

  

Employer:

Relationship to Patient:

Insurance ID#:

Insurance Group#:

Insurance Effective Date:

 

Secondary Insurance Provider:
(Bring copy of card to appointment)

Insurance Provider Phone:

Subscriber (Legal Name):

Date of birth:

Employer:

Relationship to Patient:

Insurance ID#:

Insurance Group#:

Insurance Effective Date:

 
 
 

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Our Doctors:
Hai Pham, DMD
Jenette Intrachat, DDS
Frank Hsieh, DDS, MSD

TOP DENTIST, Portland Monthly

Dr. Pham was featured in Portland Monthly, chosen
as one of the Top Dentists, Pediatric Dentistry, 2011, 2012, 2013, 2014, 2015.

Proud Member

Hospital Privileges
Dr. Pham has hospital privileges at:


Hillsboro

Hi5 Dentistry for Kids
- New Address!

3075 SE Century Blvd Ste 109
Hillsboro, OR 97123
Phone: (503) 642-1535
map
Portland

Hi5 Dental - Pediatric Dentistry
2375 SW Cedar Hills Blvd,
Portland
, OR 97225
Phone: (503) 644-4749
map
Office Hours

Monday - Thursday: 8am to 5pm
Friday: 8am to 12pm


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Hai Pham DMD - Hi5 Dentistry for Kids | www.hi5dental.com | (503) 642-1535
2375 SW Century Blvd, Hillsboro, Or 97225



 

 

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