Please enable JavaScript in your browser to complete this form.Welcome,The benefits of a happy and healthy smile are immeasurable. Our goal is to help you reach and maintain this. Pleasecomplete these forms. With good communication, we can better care for you.ABOUT YOU NamePreferred NameAddressHome PhoneCell PhoneSocial Security NumberBirth DateGenderMaleFemaleMarital StatusSingleMarriedDivorcedWidowedYour EmployerOccupationWork NumberWhom may we thank for referring you to our office?ABOUT YOUR SPOUSE (If you are married, please complete this section) Your Spouse's NameTheir Cell PhoneTheir EmployerTheir OccupationTheir Work PhoneEMERGENCY INFORMATION (Please name someone other than spouse) NameRelationshipHome PhoneCell or Work PhoneDENTAL INSURANCE Do you have dental insurance through your employer?YesNo (If yes, please complete this section.) Insurance CompanyInsurance Company AddressInsurance Company PhoneYour EmployerYour Group NumberOTHER DENTAL INSURANCE Do you have other dental insurance?YesNo (If yes, please complete this section.) Cardholder NameRelationshipTheir Birth DateTheir Social Security NumberTheir Work PhoneTheir EmployerTheir Group NumberInsurance CompanyInsurance Company AddressInsurance Company Phone By submitting this form you understand that the information you have given is correct. You authorize release of information for insurance, appointment scheduling and confirmation. You understand that you are responsible for all costs of your dental treatment, and direct payment to Dr. Bobâs Family Dental.Submit
