Thank you for selecting the Jolley dental team! To help us meet your dental needs,
please complete our New Patient History form below. If you are unable to provide
some information, it will be collected when you come in for your first office visit.
If you have any questions about this form, please call 425-432-1232.

There are three ways for you to present the form to our office:

1. You may complete the form and submit it while online or;
2. Print it out and bring the completed form with you to your next appointment or;
3. Complete it and fax the form to our office -- Fax: 425-432-2043.

Patient Information

This information is NOT shared with anyone outside this office; it is
considered strictly confidential and collected solely for the use of this office
to process for your medical/dental records chart.  The collected data will be
stored in your dental record and will not be shared with anyone without a
written consent that is signed and dated only by you.

Use your tab key to quickly advance to each field.

Last Name
  First Name   Middle Initial      
I prefer to be called 
  Date of Birth   Age
If the patient is a child, Parent(s)' Name(s)

Street Address 

  State   Zip
Home Phone (with area code)
Cell Phone
  E-Mail Address
Name of Previous Dentist
  Date of Last Visit
Work Phone
When/where is best time/place to reach you? 

Whom May We Thank For Referring You?

Spouse's Information

Spouse's Name

Work Phone
  Extension    Cell Phone

Emergency Information

Nearest Relative or Friend (not living with you)
Home Phone

Primary Dental Insurance

Insurance Company Name
Insured's Name
Insured's ID # (Plan, Local or Policy #)

Insured's Employer

Is there dual coverage?   

Responsible Party

Please complete the following only if the patient is not the party responsible for payment.

Name of P
erson Responsible for Account

Thank you for taking the time to complete this form.

View/print HIPPA Notification

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