Single Page Form Sample for Website - Healthcare General Patient Inquiry Form

Patient Name*

TitleFirst NameMiddle NameLast Name

Preferred Name

Patient Gender*

Spouses Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

SSN*

### - ## - ####

Patient Birth Date*

MonthDayYear

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Patient E-Mail*

Employer

Occupation

Are you a full-time student at a college?

YesNo

If yes, name of college

Marital Status:

How did you hear about our office?

Please check your preferred method of contact for appointment confirmation:

E-MAILCELL PHONEWORK PHONEHOME PHONE

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area CodePhone Number

Group Number

Do you have a personal physician?

YesNo

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Visit

Are you currently under the care of a physician?

YesNo

If yes, please explain

Do you use tobacco in any form?

YesNo

If yes, please list type and frequency of use

Do you have any artificial joints or implants?

YesNo

If yes, please list along with date of surgery

Are you taking any medication? If yes, please list each one

Do you have any allergies?

YesNo

If yes, please list

Do you have any disease, condition or problem that you feel we should know about? If so, please describe

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Corey L. Plaster, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Signature*

Date*

MonthDayYear

General Patient Information

Insurance - Primary

Medical History

Assignment and Release