Royal Vista Dental — New Patient Forms

Patient Information

First Name *

Last Name *

M.I.

Preferred Name

Birth Date *

Gender

MaleFemale

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

May we call you at work?

YesNo

Email Address

Preferred Contact Method

E-mailCell phoneMail

Social Security #

Driver's License #

Emergency Contact Name & Number

How did you hear about our office?

Some of your treatment may be covered by your medical insurance. If so, medical coverage will reduce your out of pocket expense.

Primary Insured (Subscriber)

DOB

Medical Insurance Co.

Employer

Subscriber ID / Soc. Sec. #

Policy #

Group #

Primary Insured (Subscriber)

DOB

Relationship to Patient

Dental Insurance Co.

Employer

Subscriber ID / Soc. Sec. #

Group #