Patient Information Form

Name:   SS#:

Date  :                                 Male  Female

Marital Status:  Married   Single   Minor                       

Address:      Apt: 

 City:   State: Kansas New Mexico Oklahoma Texas   Zip Code: 

Email:    Birth Date :

 Home Phone:      Work Phone:  Cell Phone:

Employer or School: 

Grade (if applicable):   

Employer Address: 

City:    State: Kansas New Mexico Oklahoma Texas   Zip:

Has any member of your family ever been treated in our office?  Yes No

Whom may we thank for referring you to our office?

FAMILY INFORMATION

In the computer we link family members together in one account.  Please list other immediate family members that are patients here:

If the patient is a minor:

Mother:

Father: 

CHIEF COMPLAINT

What are you being treated for today?

Which dentist are you seeing?

Dr. Edward Sauer         Dr. Scott Sauer           Dr. Ryan Brewster

INSURANCE INFORMATION

Insurance Company: 

Address: 

City/State/Zip: 

Phone Number: 

Cardholder's Name: 

Cardholder's birth date: 

Cardholder's SS #: 

Insurance ID #: 

Card Holder's Employer:

Relationship of Patient to Insured:    Self      Spouse    Child

PERSON TO CONTACT OUTSIDE OF IMMEDIATE FAMILY IN CASE OF EMERGENCY:

Name: 

Telephone: 

Cell Phone: 

THANK YOU FOR PROVIDING THIS IMPORTANT INFORMATION

Please click the Submit button to transfer your information securely to our office.