Active Life Dentistry Online Patient Paperwork

Please fill out the fields below to complete your Active Life Dentistry patient paperwork. Fields marked with an asterisk (*) are required. You must complete each page fully before you can move to the next page. Clicking any “Agree” field constitutes your electronic signature, signifying your intent to sign the applicable section, page or document (as applicable), to be as fully binding as if you had entered your signature by non-electronic means.

Which Office are you Visiting for Your Next Appointment? *NOTE - Bridgeland Dentistry is no longer using this form. *

Patient Information - Page 1 of 7

Last Name *

First Name *

Middle Initial

Preferred Name *

How did you hear about us?

If Family/Friend, who referred you?

If Other, please explain.

Social Security Number *

Date of Birth *

Marital Status *

Biological Sex *

Email - If you provide an email address, a copy of this paperwork will be emailed to that address.

Phone - Required *

Phone Type - Required *

Other Phone

Other Phone Type

Home Address *

Home Address Line 2

City *

State *

ZIP Code *

Preferred Active Life Dentistry Location *

Employer Information

Employer

Work Phone

Work Address

Work City

Work State

Work ZIP Code

Emergency Contact

Emergency Contact *

Relation *

Phone *

Primary Dental Insurance Information

Do You Have Dental Insurance?

Yes

No

Name of Insurance Company *

Phone

Address

City

State

ZIP Code

Policy Number *

Group Number

If Patient is Not the Primary Insured

Are You the Primary Insured? *

Yes

No

First and Last Name of Primary Insured *

Relationship to Patient *

Address if Different From the Patient Address *

City *

State *

ZIP Code *

Social Security Number of Primary Insured *

Email Address of Primary Insured

Employer of Primary Insured *

Phone Number of Primary Insured *

Work Phone