. . .

Date:__________

Name________________________________________________Age___________

Street______________________________________________________________

City, State, Zip_______________________________________________________

Home telephone_(____)________________________

Business telephone_(____)______________________

Marital status_________________Name of spouse___________________________

Occupation_____________________________________________

Name of employer________________________________________

Employer's address_______________________________________

Social Security number______________________________

Referred by______________________________________

General dentist____________________________________

Dental specialists__________________________________________

Family doctor____________________Telephone_(____)__________

Other medical doctors______________________________________

______________________________________

Dental insurance carrier_____________________________________

Second insurance carrier____________________________________

Insurance coverage: Preventative_____% Basic_____% Major_____%

Annual maximum $______________Deductible $____________

Dental insurance telephone number_(____)_________________

Dual coverage exists? Y N (circle)

Miscellaneous information: _______________________________________________

___________________________________________________________________

Print this document, fill it out, and bring it to your initial visit. Thank you for filling out this form.

Dr. Russin and Staff