New Patient

It is our pleasure to serve you! Please fill out the information completely. The better we communicate, the better we can help you. If you have any question, please ask.

Step 1 of 7

Name*
First Last Suffix
First Name Preference
First
Home*
Cell Phone*
Work*
Ext*
Date*

DD
MM
YYYY
Gender*
- Male
- Female
SSN*
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Mailing Address(If different)
Street Address City State / Province / Region ZIP / Postal Code
Email Address*
Optional:
- Single
- Married
- Widowed
- Divorced

Employer
How long there?
Occupation
Other family members seen by us
Name
Full Name
Employer
work#
Ext#

Primary Dental Insurance
Insurance Company Name
Insurance Company Address
Street Address
Insurance Company Phone
Group # (group, plan, and policy)
Insured's Name
Relationship to patient
Insured's Birth Date

DD
MM
YYYY
SSN

Secondary Dental Insurance
Insurance Company Name
Insurance Company Address
Street Address
Insurance Company Phone
Group#(group,plan And policy)
Insured's Name
Relationship to patient
Insured's Birth Date

mm
dd
yyyy
SSN

In the event of emergency
Is there someone that we could contact?
Name
Relationship
Work#
Home#
Fees in this of are less than the average for general dentistry in the United States. Please help us keep our fees low by coming to each appointment on time. When a change of appointment is necessary, 48 hours notice is requested.

This enables us to offer your reserved time to other patients who need our services. Typically a $15-$50 charge will be made for broken appointments where at least 24 hours notice is not given. I authorize payment of my insurance benefits directly to Dr. C. Ray Coleman.

I authorize the release of any information concerning medical history, Illness, or injuries to Insurance carriers. A photocopy of this authorization shall be as valid as the original. I understand that I am financially responsible for all charges whether or not paid by insurance. I further agree to pay interest at the rate of 1-1/2% per month (18% per year). I agree to pay all attorney fees, court cost, filing fees, including commission, up to 40%, that may be assessed to me by a collection agency rained to pursue this matter. I hereby authorize said assignee to release all information necessary to secure payment.
Your current physical health is
- Good
- Fair
- Poor
Physician's Name
Have you been to physicians within the past year?
- Yes
- No
If yes, why?
Are you taking any prescription, diet, or over the counter drugs?
- Yes
- No
If yes, specify the name and purpose of each medication

C, Ray Coleman,

General Dentistry

3165 West 4700 South Salt Lake City, Utah 84118
(801) 966-9956
(801) 969-1612
Fax: (801) 969-7004

New Patient

Step 1 of 7

Primary Dental Insurance

Secondary Dental Insurance

In the event of emergency

C, Ray Coleman,