- Personal Information -

Name of Patient ______________________________________________     Date ____________________

 Male_____   Female_____   Birthdate______________   Social Security # _______-_______-___________

 Minor (under 18) _____   Single _____    Married _____    Divorced _____   Widowed _____   

 E-Mail: ______________________   Home #_____-______-________     Cell # _____-______-_______

Employer: __________________________   Work Phone # _____-_____-_______ Ext. _______

Occupation _________________________          How Long At Present Position __________                                          

- Responsible Party -

Name _____________________________              Relationship to Patient ______________________

Home # ______-______-________                     Social Security # ______-_____-______________

Address/City/State/Zip ____________________________________________________________________

- Dental Insurance Information -

Name of Insured _____________________________     Relationship to Patient ______________________

Insured’s Birthdate _______________ Social Security # _____-_____-________  Employer______________

Insurance Company__________________________  Group #___________  Phone #_____-_____-______

- Other Information -

Who may we thank for referring you? _________________________________________________________

In the event of an emergency, who should we contact? ____________________________________________

Relationship _____________________   Home # ____-______-________   Cell # ____-______-________

Reason for this visit ______________________________________________________________________

- Billing Information -

LATE CHARGES: If your entire balance is not paid within 30 days of the monthly billing date, a late charge of 1.8% on the balance will be assessed each month. Failure to keep this account current may result in Peppes Dental being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. CANCELLATION POLICY: There will be a $30 charge on missed appointments not cancelled 24 hours in advance

____________________________________________                ______________________

Signature of patient, minor’s parent or responsible party                       Today’s Date