Full Name Date

Address

Phone Home Work

Marital status

Date of birth S.S.#

Employer Spouse's Name

Has any member of your family every been treated in our office? Yes No

Whom may we thank for referring you to our office?

Person financially responsible for this account

DENTAL INSURANCE INFORMATION

Insured's Name Address

Phone Home Work

Employer

Ins. Company Name Phone

Address Group #

EMERGENCY INFORMATION

Person to Contact in Case of Emergency

Phone Home Work

AUTHORIZATION

I hereby authorize release of any information relating to dental treatment to my dental insurance company for processing of dental claims.

I hereby give Dr. Stephen Miller the abosolute right and permission to use mu photographs/slides for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides.

Signature