Get New Patient Form ( Pdf ) - Hde Periodontal

This guide will help you navigate the New Patient Form for HDE Periodontal. By following these steps, you will be able to complete the form efficiently and accurately, ensuring that your information is submitted correctly for your dental appointment.

Follow the steps to complete your New Patient Form.

1. Press the ‘Get Form’ button to obtain the form and open it in your chosen document editor.
2. Begin by filling in your name details, including your last name, first name, and middle initial as required.
3. Input your address, including street address, city, state, and zip code. This information is vital for communication and locating you in our system.
4. Provide your home and cell phone numbers, along with your email address, so we can contact you regarding appointments and important updates.
5. Indicate your preferred method of receiving calls — home, work, or cell phone — by marking the appropriate box.
6. Fill in gender, age, date of birth, and marital status by selecting the appropriate options.
7. Complete the employment section by entering your employer's name, occupation, and business phone number.
8. Identify your general dentist, if applicable, and any referral source by stating whom to thank for referring you.
9. In the emergency contact section, provide the name and contact numbers of the individual we should notify in case of an emergency.
10. Enter the name of your physician, their phone number, and the date of your last physical check-up.
11. For insurance details, fill in the information for your primary dental insurance, including the person responsible for the account and their relation to you.
12. If applicable, answer whether you have additional dental insurance by marking 'Yes' or 'No', and fill in the necessary details if applicable.
13. Once you have filled out all sections, review your entries for accuracy. You can then save your changes, download the form, print it, or share it as needed.

Complete your New Patient Form online today to ensure a smooth start to your dental care experience.