This is information a dental practice should include when creating a New Patient Form. CDA also recommends that dental practices verify with the responsible individual certain information periodically. The information to verify includes:

• Employment status.
• Benefit plan status.
• Address and contact phone numbers.
• Status of minor when they turn 18.

Patient Information

• Patient first name, middle initial, last name, nickname, preferred pronoun
• Date of birth
• Marital status
• Occupation
• Is the patient a minor? 
• Minor patient’s primary residency:
  • both parents
  • mother
  • father
  • stepparent
  • legal guardian
• Minor patient’s school
• Patient emergency contact name, contact information, and relationship to patient

Information of Individual Financially Responsible

• Responsible individual 
• Responsible individual’s address
• The patient’s address is 1) same or 2) different. If different, provide the patient's address.
• Telephone numbers of the responsible individual: home, work, cell*
• Please indicate which of the above telephone numbers we may use to contact you regarding appointments, treatment, and your account
• Email address of the responsible individual
• Responsible individual’s Social Security number
• Responsible individual’s employer, employer address, and employer telephone number
• Number of years at employer/business
• Responsible individual’s occupation
• Responsible individual’s relationship to patient

* Note: If collecting a cell phone number, be sure to include the appropriate authorization, for example, “By providing your cell phone number, you consent to being contacted at that number by our practice and our agents regarding treatment and your account.

Dental Benefit Information

• Name of primary dental plan and contact information
• Sponsor of the dental plan:
  • Employer
  • Self
  • Other/Name  _______
• Name of insured
• Insured’s date of birth
• Subscriber number
• Relationship of the patient to insured
• Name of secondary dental plan and contact information
• Sponsor of the secondary dental plan:
  • Employer
  • Self
  • Other/Name _______
• Name of insured
• Insured’s date of birth
• Subscriber number
• Relationship of the patient to insured

Medical Plan Information

• Name of the medical plan and contact information
• Sponsor of the medical plan:
  • Employer
  • Self
  • Other/Name _______
• Name of insured
• Insured’s date of birth
• Subscriber number
• Relationship of the patient to insured
• For Kaiser Patients Only - Medical Record Number

Other Information

• Whom may we thank for referring you? If you were not referred to us, how did you hear about our practice?
• List other members of your immediate family who are patients in our practice.
• If the patient is a minor, will someone other than a legal guardian accompany the patient to appointments at our practice?
  • If yes, please complete the Authorization for a Caretaker to Accompany a Minor Patient form.