Healthy Smiles Family Dentistry

856-768-8988

Welcome!
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we’ll be glad to help you. We look forward to working with you in maintaining your dental health.

Patient/Guardian’s Email Address:

How you heard about us:

If somebody referred you, please tell us their name, we would love to thank them:

If you have dental insurance,
please fill out the area below completely

Primary Dental Insurance

Person Responsible for Account:

Relation to patient:

Date of Birth:

Soc.Sec.#

Address:

(if different from patient)

City:

State:

Zip:

Home:

Person Responsible Employed by

Occupation

Business Address:

Business phone

Insurance Co.

Insurance company phone #

Group #

Subscriber #

Names of dependents under this plan

Additional Dental Insurance

Patient covered by additional dental insurance? Yes No

Subscriber Name:

Relation to patient:

Date of Birth:

Soc.Sec.#

Subscriber Employed by

Business Ph.#

Insurance Company:

Phone:

Group #

Subscriber

Address: 1233 Haddonfield-Berlin Road, Suite 6, Voorhees, NJ 08043	TEL: 856-768-8988 FAX: 856-768-2518	General Inquiries: healthysmilesfamilydentistry@gmail.com By: Zealousweb, Web Design Company, USA
		© 2009 Healthy Smiles Family Dentistry