Cary Office Click To Call
(919) 865-0700
1110 SE Cary Parkway Ste # 206
Cary, NC 27518, USA | Directions
Cornelius Office Click To Call
(704) 765-3150
20905 Torrence Chapel Rd #201
Cornelius, NC 28031, USA | Directions

Welcome

Print blank form to fill by hand
Please note that it is important to fill in the fields before submitting. Thank you.


*Last name :
*Fist name :
M.I :
*Birthday :
How you wish to addressed :
Status : SingleMarriedDivorcedWidowedMinor
*Patient address :
Street
City
State
Zip
Apt#
Employer :
Employer address :
Street
CityState
Zip
Position :
How long?
Telephone home : ()--
Business Phone : ()---
Cell : ()--
Email address :
SSN :
Driver’s license no :State
Spouse/Parent name :
Spouse / Parent address :
Street
CityState
Zip
SSN :
Employer :
Position :
How long?
Emergency contact :
Telephone home : ()--
Cell : ()--
Purpose of first visit :
Other family members in practice :
How did you hear about us?
Have you visited our website? Yes No Visit Our Website
Referred by :
Who is responsible for this account?
Method of payment : Cash CC/Debit Check AMEX
Note :Care Credit are not accepted.
Dental insurance coverage
Subscriber name :
Birthday :
Employer of
insured :
Name of ins co. :
Insurance address :
Street
CityState
Zip
Relationship of patient to
subscriber :
Telephone of ins. co. : ()--
Policy :
Group :
ID no or SSN :
*I consent to the diagnostic procedures and treatment necessary for proper dental care. I consent to the dentist’s use and disclosure of my records (or my child’s) to carry out treatment, to obtain payment and for those activities and health care operations that are related to treatment or payment. My consent to disclosure of my Records shall be in effect until I revoke it in writing.
*I attest to the accuracy of the information I have provided on
this page.
*Patient or Guardian signature :
Date :