Patient Medical Information

Perfect Smile - Portland & Falmouth Maine General and Cosmetic Dentist

Please take the time to fill out this form online to save you time when you come in for your appointment. Or fill out this printable version and bring it in with you on the day of your appointment.

Patient Information

Today's Date:

First Name: *

Middle Initial:

Last Name: *

Is this your legal name?

If not, what is your legal name?

Preferred Name (nickname):

Name Prefix:

Marital Status:

Date of Birth:

Age:

Social Security Number:

Sex:

Address:

P.O. Box:

City:

State:

Zip Code:

Seasonal Home Address:

Home Phone:

Cell Phone:

Email:

Who may we thank for referring you:

Other family members seen here:

Employer Information

Employer:

Employer Address:

Employer Phone:

Insurance Information

Person responsible for bill:

Date of Birth:

Address:

City:

State:

Zip Code:

Is this person a patient here?

Employer:

Employer Address:

Employer Phone:

Are you covered by DENTAL insurance?

Insurance Company Name:

Subscriber's Name:

Subscriber's Date of Birth:

Group Number:

Subscriber Number:

Patient's relationship to subscriber:

In Case of Emergency

Emergency Contact (not living at same address):

Relationship to patient:

Home Phone:

Work Phone:

Cell Phone:

Acknowledgment to Receive Notice of Privacy Practices

In accordance with the privacy law under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, our office must take reasonable steps to limit the use or disclosure of, and requests for, your protected health information. Under this law we are also required to provide you access to our privacy practices, which details how health information about you may be used and how you may access this information.

We ask that you check the box below to acknowledge that you have been made aware that you may request a copy of our privacy practices at any time.

I acknowledge that I have been made aware that I may request a copy of your privacy practices at any time. *

Mind helping us stop spam? Please type the number from the image to the field below.
Captcha Image

Fields with * are required.

A Perfect Smile values your privacy and will NEVER submit your information to a third party. For more information, see our privacy policy.