Patient Questionnaire

Please fill out the form below to allow us to better help you.

Last Name: First Name: E-mail Address:

Sex: Marital Status:
Patient's Information:
Last Name:
First Name:
E-mail Address:
Home Phone:
Work Phone:
Address 1:
Address 2:
City:
State: Zip Code:
Driver's Lic. No.:
Social Security #:
Employer:
Address 1:
Address 2:
City:
State: Zip Code:
Position:
No. Yrs.:
Spouse's Information:
Last Name:
First Name:
spouses-email-address:
Home Phone:
Work Phone:
Address 1:
Address 2:
City:
State: Zip Code:
Driver's Lic. No.:
Social Security #:
Employer:
Address 1:
Address 2:
City:
State: Zip Code:
Position:
No. Yrs.:

Dental Insurance Information
Insured Last Name: Insured's First Name:
Insured's Soc. Sec. No.: Dental Insurance Co.:
Group No.: Local No.:
Insurer's Address 1: Insurer's Address 2:
City: State: Zip Code:
Date of Marriage (mmddyy): Date of Employment (mmddyy):
Effective Date of Dental Insurance (mmddyy):
In case of emergency, please notify:
Last Name:
First Name:
Home Phone:
Work Phone:
Address 1:
Address 2:
City:
State: Zip Code:
In case of emergency, please notify:
Last Name:
First Name:
Home Phone:
Work Phone:
Address 1:
Address 2:
City:
State: Zip Code:

Whom may we thank for referring you?

I, the undersigned certify that I (or my dependent) have insurance coverage with the above stated company and assign benefits directly to Dr. Spiker Davis. By checking the box located next to this text I authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions. This office will file claims only for services that exceed $500. We will estimate the patient portion and that will be due the day services are rendered.
[ Check Here to Affirm ]