Adult Information 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


ABOUT YOUR SPOUSE

(If you are married, please complete this section) 


EMERGENCY INFORMATION

(Please name someone other than spouse) 


DENTAL INSURANCE


(If yes, please complete this section.)

OTHER DENTAL INSURANCE


(If yes, please complete this section.)


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. Bob’s Family Dental.