Village Family Dental - New Patient 1 of 4

New Patient
Forms - 1 of 4

New Patient Forms

HIPPA

Schedule an Appt.

Financial Information

FAQ's

VFD Links

New Patient PDF

We appreciate your loyalty
and referrals to friends, family
and acquantances!


Today's Date:
Last Name:
First Name
Middle Initial:
Birth Date:
Sex:	Male Female
Marital Status:	Single Married Divorced Widowed Minor
SS#:
If Child-Parent's Name:

Home Phone:
Cell Phone:
Work Phone:
Contact at Work?	Yes No
Email Address:
Best Contact:

Street Address:
City:
State:
Zip Code:
Patient/Parent Employer:
Business Street Address:
Business City:
Business State:
Business Zip Code:

Spouse Name:
Spouse SS#:
Spouse Employer:

Responsible Party:
Drivers License #:

Do you have insurance that may cover a portion of the charges?

Family members in this practice:
Subscriber's Birth Date:
Subscriber's SS#:
Subscriber's Employer:
Emergency Contact:
Who referred you?

Why did you change Dentists?

RELEASE I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child’s) health care, advice and treatment to another dentist. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor. I attest to the accuracy of the information on this page.

Accpet These Terms:

Patient Quote: