* = Required Information
Patient Information
Male Female
Single Married Separated Divorced
Widowed
Full-time Part-time
Full-time Part-time Retired N/A
Emergency Contact:
Parent/Guardian Information (if patient is a minor or over the age of 18 and still on parent/guardian's insurance)


Primary Dental Insurance

Primary Medical Insurance

Secondary Dental Insurance

Secondary Medical Insurance
Health History
Do you have, or ever had any of the following?
Yes No
Yes No
Yes No
Yes No
Yes No
Cardiovascular Disease (Heart Problems)
Yes No
Yes No
Yes No
Yes No
Lung Disease
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Allergies: Are you allergic, or have you had a reaction to:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Are you using or taking any of the following:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Women Only
Yes No
Yes No
Yes No
NOTE: Antibiotics(such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Yes No
Yes No
I , hereby authorize Dr. Steven Green or Dr. Harold Wallin to furnish to the above insurance company(s) or to a designated attorney all information, which said insurance company(s), or attorney request. I hereby assign to Dr. Steven Green or Dr. Harold Wallin all money to which I am entitled for medical and/or dental surgical expenses relative to the service rendered by him. It is understood that any money received from the above named insurance company over and above my indebtedness will be funded to the appropriate party when my bill is paid in full. I understand I am financially responsible to said doctor for all charges. I further agree in the event of non-payment, to bear the cost of collection and/or court and reasonable legal fees should this be required.
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