Welcome to Tara Hills Dental
Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all you dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us – we will be happy to help!
Patient Information (CONFIDENTIAL)
First Name *
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Last Name *
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Birthdate *
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Date *
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YYYY
Address *
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City *
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State/Zip *
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Email
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Home Phone *
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Cell Phone *
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Soc. Sec. # *
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Check Appropriate Box: *
Patient’s Employer *
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Work Phone *
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Business Address *
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City *
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State/Zip *
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Spouse or Parent/Guardian’s Name *
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Work Phone *
Your answer
Spouse or Parent/Guardian’s Employer *
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City *
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Whom May We Thank for Referring You? *
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Person to Contact in Case of Emergency (living in same home) *
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Phone *
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Person to Contact in Case of Emergency (not living in same home) *
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Phone *
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