Smile LA - New Patient Information Form
Thank you for selecting our dental healthcare team! To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us. We will be happy to help.
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How did you hear about our office?
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Personal Information  (CONFIDENTIAL)
Patient’s Name *
Address *
(Street #, Street, City, State, Zip)
Home Phone #
Work Phone #
Cell Phone #
Email address *
Soc Sec # *
Date of Birth *
MM
/
DD
/
YYYY
Driver’s lic. # *
Employer
Occupation
Employer Address
(Street #, Street, City, State, Zip)
Name of School / College
City & State of College
Full Time or Part Time College Student
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Spouse’s Name
Spouse's Employer
Spouse's Soc Sec #
Spouse's Birth date
MM
/
DD
/
YYYY
Spouse's Work Phone #
Name of nearest relative not living with you
Relationship
Complete Address
Phone Number
Emergency Contact
Phone Number
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