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.
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Patient First Name: *
Patient Middle Name:
Patient Last Name: *
Patient Nick Name:
PDX Center may email confirmations, financial treatment plans, insurance information, and x-rays to myself or other dental providers:
Patient Email: *
Home phone: *
Work phone:
Cell phone:
Preferred way to contact: *
Mailing address: *
City: *
State: *
Zip: *
Date of birth: *
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Patient Gender: *
Preferred Language:
SSN:
Referred By:
Emergency Contact Name:
Emergency Contact Phone:
Is Patient a Student:
Name of School:
City where shool is located:
Patient Employment Status:
Patient Marital Status:
Other family members seen at the same office:
Does the patient have dental insurance? *
Primary Insurance
Subscriber Name:
Employer:
Insurance Company:
Insurance Company Phone #:
Insurance Company Address:
Group #:
ID #:
Subscriber Birth Date:
Subscriber Social Security #:
Secondary Insurance
Subcriber Birth Date:
Does the patient have medical insurance?
Guarantor Information: *
Guarantor First Name:
Guarantor Middle Name:
Guarantor Last Name:
Guarantor Email:
Guarantor Home Phone:
Guarantor Cell Phone:
Guarantor Work Phone:
Guarantor Mailing Address:
Guarantor City:
Guarantor State:
Guarantor Zip Code:
Guarantor Date of birth:
Guarantor Gender
Guarantor SSN:
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