Local Dentist Office | Sioux Falls, SD

New Patient Form

New Patient Form

We would like to welcome you to our practice. Our goal is to help improve and maintain maximum oral health. Thank you for choosing us for your dental health care needs.

Child's Information & Health History

Free Text

PERSONAL INFORMATION

First Name:

Last Name:

Date of Birth:

Age

Gender:

S.S. Number:

Street Address:

City:

State

Zip:

Email Address:

Marital Status:

Home Phone:

Pager/Cell

Work Number

Ext.

DL Number

Employer

New Field:

How long there?

Who may we thank for referring you?

Other family members seen by us?

Previous/Present Dentist

Last Visit Date

Insurance

INSURANCE

(Primary Insurance)

With Dental Coverage?

Insurance Company Name

Insurance Company Address

Insurance Company Phone

New Field:

Insured's Name

Relation

Insured's Birthday

Insured's Employer

Employer's Address

Secondary Insurance

(Secondary Insurance)

With Dental Coverage?

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Group # (Plan, Local or Policy #)

Insured's Name

Relation

Insured's Birthday

Insured's Employer

Employer's Address

Neighbor or relative not living with you

(Neighbor or relative not living with you)

His/Her Name

Relation

Work Number

Home Number

Address

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Contact Details

Phone: (605) 336-1967

Email: office@paulsondental.com

Address: 2521 S. Western Ave.

Sioux Falls, SD, 57105

Find Us On:

Business Hours

Mon - Thu: 8:00 am - 5:00 pm
Friday: 8:00 am - 12:00 pm
Sat - Sun: Closed

By appointment only