Initial Patient Information Form - All About Yue Orthodontics

All About Yue Orthodontics

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PATIENT INFORMATION

Patient Name(Required)

Prefix First Middle Last

Name Called

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Mobile Phone(Required)

Home Phone

Patient's Address(Required)

Street Address Address Line 2 City State ZIP Code

Dentist(Required)

Email(Required)

Reason for Visit(Required)

Who referred you to our office?(Required)

Does this patient have a responsible party?(Required)

No

Yes, they have one responsible party

Yes, they have two responsible parties

RESPONSIBLE PARTY #1 INFORMATION

Responsible Party Name #1(Required)

Prefix First Middle Last

Name Called

Date of Birth(Required)

MM slash DD slash YYYY

18 years or older.

Mobile Phone(Required)

Home Phone(Required)

Responsible Party's Address(Required)

Street Address Address Line 2 City State ZIP Code

SSN(Required)

Relationship to Patient(Required)

Sex(Required)

Male

Female

Is this Responsible Party Financially Responsible for Charges?(Required)

Yes

No

Is this the Primary Person who brings patient to appointments?(Required)

Yes

No

Do you have Dental Insurance?(Required)

Yes

No

Dental Insurance(Required)

Member ID Number(Required)

Group Number(Required)

Insurance Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

RESPONSIBLE PARTY #2 INFORMATION

Responsible Party Name #2(Required)

Prefix First Middle Last

Name Called

Date of Birth(Required)

MM slash DD slash YYYY

18 years or older.

Mobile Phone(Required)

Home Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

SSN(Required)

Relationship to Patient(Required)

Sex(Required)

Male

Female

Is this Responsible Party Financially Responsible for Charges?(Required)

Yes

No

Is this the Primary Person who brings patient to appointments?(Required)

Yes

No

Do you have Dental Insurance?(Required)

Yes

No

Dental Insurance(Required)

Member ID Number(Required)

Group Number(Required)

Insurance Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

INSURANCE AND EMPLOYER INFORMATION

Do you have Dental Insurance?(Required)

Yes

No

Dental Insurance(Required)

Member ID Number(Required)

Group Number(Required)

Insurance Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

ADDITIONAL INFORMATION

List Family Members that are currently in our practice

Other Information

Signature of Patient, Parent, or Guardian(Required)

Today's Date(Required)

Month

Day

Year

275 W. Elk Trail
Carol Stream, IL 60188
630-882-0988

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