Please fill out this form and print it before your first appointment. Download PDF here.
Last name: First name Middle: Sex M F
Marital status: Single Married Divorced Separated Widowed Mr. Mrs. Dr. Ms. Birth date: Age
Preferred name: Email address:
Street address: Driver's license no.:
City State: Zip code: Social Security Number:
Home phone: Second phone: Occupation: Employer:
Chose Dr. Ehrlich because/Referred by: Dr. Insurance plan Website Family Friend Close to home/work Yellow Pages Other
Other family members seen here:
Insurance Information
Person responsible for bill: Birth date: Home phone:
Address (if different):
Is this person a patient here? Yes No Occupation:
Employer: Is this patient covered by insurance? Yes No
Employer address: Employer phone:
Please indicate primary insurance Idemnity PPO Other
Subscriber's name Subscriber's SSN Birth date:
Group number: Patient's relationship subscribers: Self Spouse Child Other
In Case of Emergency
Name of local friend or relative: Relationship to patient:
Home phone: Work phone:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Joshua H. Ehrlich, DMD PC. I understand that I am financially responsible for any balance. I also authorize Dr. Ehrlich or my insurance company to release any information required to process my claims. Finally, I affirm that I have been offered and read the Office Privacy Policy according to HIPAA.
Patient/Guardian signature __________________________________________ Date _____________________
