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To help us render the proper dental services to you, please be kind enough to answer the following questions.

PATIENT

Name

Address

City/State/Zip

Birthdate / Sex

M F

What would you like us to call you?

Whom should we call to confirm appointments?

Phone

Whom should we call in case of emergency?

Phone

Whom should we thank for referring you to us?

Do you have any family members already in our practice?

Yes No

Who?

PERSON PAYING ACCOUNT

Name

Address

City/State/Zip

Birthdate / Driver's License #

Social Security #

Hm. Phone / Wk. Phone

Occupation / Length of Employment

Employer

Address

City/State/Zip

Place, time and number, during the day, to reach by phone

IF YOU HAVE DENTAL INSURANCE, PLEASE PROVIDE THE FOLLOWING

INS. COMPANY #1

Address

City/State/Zip

Phone

Birthdate / SSN

Employee Name

Employer Name

Address

City/State/Zip

Group #

INS. COMPANY #2

Address

City/State/Zip

Phone

Birthdate / SSN

Employee Name

Employer Name

Address

City/State/Zip

Group #

Our office policy is to request payment of fees at the time of service, or to collect your portion if you have insurance. For your convenience we accept cash, check, or Visa/MasterCard. With credit approval we can provide an extended payment plan. Account balances over 90 days past due will be charged a 1-1/2% per month (18% per annum) finance charge. A charge of $10.00 will be made for all returned checks. We reserve the right to charge $50.00 for all missed appointments, or for cancellations with less than 72 hours notice.

I acknowledge full responsibility for the payment of services. I authorize Livermore Dental Care to bill my insurance company(ies), and I authorize all insurance benefits to be paid directly to Livermore Dental Care.

Physician / Phone

MEDICAL HISTORY PART 2

Allergies to any medications?

Has your child ever been hospitalized?

Does your child have any developmental or emotional conditions that would help us care for your child?

Was your child's birth premature?

List any current medications that your child takes

CONSENT

To the best of my knowledge, all of the preceding answers are true.
If my child has any changes in health or medications, I will inform the doctor at the next appointment.
I grant permission to this office to contact any of my child’s healthcare providers regarding any medical or dental condition.

Signature of responsible party:

Click to Sign

Date:-------------

Relation to Patient:

1171 Murrieta Blvd.
Suite 101
Livermore, CA 94550

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NEW PATIENT GENERAL INFORMATION

PATIENT

PERSON PAYING ACCOUNT

INSURANCE INFORMATION

IF YOU HAVE DENTAL INSURANCE, PLEASE PROVIDE THE FOLLOWING

CHILD MEDICAL & DENTAL HISTORY

MEDICAL HISTORY

MEDICAL HISTORY PART 2

DENTAL HISTORY

CONSENT

Click to Sign

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Main Header

NEW PATIENT GENERAL INFORMATION

PATIENT

PERSON PAYING ACCOUNT

INSURANCE INFORMATION

IF YOU HAVE DENTAL INSURANCE, PLEASE PROVIDE THE FOLLOWING

CHILD MEDICAL & DENTAL HISTORY

MEDICAL HISTORY

MEDICAL HISTORY PART 2

DENTAL HISTORY

CONSENT

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.