New Patient Form - Chicago Dental Arts

Chicago office

(312) 642-6631

Skokie office

(847) 676-0484

Hinsdale office

(708) 246-1666

Contact us

Schedule Appointment

Patient Registration Form

First Name:

Last Name:

Middle Initial:

Preferred Name:

Birth Date:

SS#:

Address:

Apt#:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Yes, send me Text Message alerts.

Email:

Yes, send me Email alerts.

Gender MaleFemale

Marital Status: MarriedSingleOther

Emergency Contact:

Phone:

Previous Dentist/Dental Office:

Driver’s License #:

Responsible Party (if someone other than the patient)

First Name:

Last Name:

Middle Initial:

Birth Date:

SS#:

Drivers License #:

Address:

Apt#:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Gender MaleFemale

Marital Status: MarriedSingleOther

Who can we thank for referring you?

Walk-InInsurance CarrierWebsiteGoogleYelpSocial Media

I was referred by:

Other:

Primary Insurance Information

Name of Insurance Company:

Insurance Phone #:

Policy Holder Name:

Birth Date:

Member ID:

Member SS#:

Plan/Group #:

Name of Employer:

Relationship to Insured: SelfSpouseChildOther

Secondary Insurance Information

Name of Insurance Company:

Insurance Phone #:

Policy Holder Name:

Birth Date:

Member ID:

Member SS#:

Plan/Group #:

Name of Employer:

Relationship to Insured: SelfSpouseChildOther