Wufoo

General Patient Information
Today’s Date MM / DD / YYYY
Last Name
First Name
MI
If Child, Parent or Guardian’s Name
Address
City, State, Zip
Home Phone
Cell Phone
Work Phone
Work Phone Extension
Birth Date MM / DD / YYYY
Gender
Male Female
Emergency Contact
Name
Emergency Contact
Phone Number
Emergency Contact
Relationship to You
Physician
Name
Physician
Phone Number
Dentist
Name
Dentist
Phone Number
The LCC Dental Hygiene Clinic utilizes the phone system for notification of patient appointments. This process may include leaving voice mail messages (check all that apply)
Home Phone
OK to leave a detailed message on machine/phone OK to leave a message with call-back number only OK to leave message with family member
Cell Phone
OK to leave a detailed message on machine/phone OK to leave a message with call-back number only OK to leave message with family member
Work Phone
OK to leave a detailed message on machine/phone OK to leave a message with call-back number only OK to leave message with family member
If you selected "OK to leave message with family member," please indicate who:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature of Patient, Parent, or Guardian
Date MM / DD / YYYY
Do Not Fill This Out