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Welcome.
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
Child
If the patient is a child, Parent(s)' Name(s)
Street Address
City
State Zip
Home Phone (with area code)
Cell Phone
E-Mail Address
Name of Previous Dentist
Date
of Last Visit
Occupation Employer
Work Phone
Extension
When/where is best time/place to
reach you?
Whom May We Thank For Referring You?
Spouse's Information
Spouse's Name
Employer
Work Phone
Extension
Cell Phone
Emergency Information
Nearest Relative or Friend (not living with
you)
Relationship
Home Phone
Primary Dental Insurance
Insurance Company Name
Insured's Name
Relationship
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 Person Responsible
for Account
Relationship
Telephone
Thank you for taking the time to complete this form.
View/print HIPPA Notification
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