New Patient Information Form

Steven E. McComb, D.D.S.
Tony C. Jewett, D.D.S.
236 W. 3rd St.
Chico, CA 95928
Phone (530) 342-8314; Fax (530) 342-8362

Patient Information (Confidential)

SS#

Date
Preferred contact method: (check appropriate box)
Name
Birthdate
Home Phone
E-mail Address *
Cell Phone
Address
City
State
Zip
If Student, Name of School/College
City
State
Patient or Parent/Guardian’s Employer
Work Phone
Employer Address
City
State
Zip
Spouse or Parent/Guardian’s Name
Employer
Work Phone
Emergency Contact
Phone
If yes, please designate below:
I authorize Dr. McComb to release information regarding my dental treatment and/or account to
Relationship
Primary Care Physician
Phone
How did you hear about our office?

Responsible Party (Complete if Parent/Guardian of patient is financially responsible )

Name of Person Financially Responsible for this Account
Relationship to Patient
Address
Home Phone
E-mail Address
Cell Phone
Driver's License
State
Birthdate
Employer
Work Phone
SS #

Dental Insurance Information

Name of Insured
Relationship to Patient
Birthdate
SS #
Employer
Union or Local #
Work Phone
Employer Address
City
State
Zip
Insurance Company
Group #
Policy/ID
Insurance Company Address
City
State
Zip

DO YOU HAVE ADDITIONAL INSURANCE?

***IF YES, COMPLETE THE FOLLOWING
Name of Insured
Relationship to Patient
Birthdate
SS #
Employer
Union or Local #
Work Phone
Employer Address
City
State
Zip
Insurance Company
Group #
Policy/ID
Insurance Company Address
City
State
Zip
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