Patient Form | Gregg O Wilcox DMD

Downloadable Forms

We love to make our patients’ lives easier! You can find all patient forms on this page, if you have any questions about which forms you need please contact our office.

Please download, print, and fill out these forms prior to your arrival at our office. You can bring the forms in with you, or fax them to our receptionist at 860-412-0209.

Medical History Form

Medical History Form (2)

HIPAA Consent Form

HIPAA Authorization

HIPAA Privacy Practices

Patient info

Home Address

City/State/Zip

Home Phone

Marital Status

If student:

Name of School/College

City/State/Zip

Full or Part Time

Patient’s or Parent’s Employer:

Business Address

City/State/Zip

Work Phone

Cell Phone

Spouse or Parent:

Name

Employer

Work Phone

Whom may we thank for referring you?

Person to Contact in Case of an Emergency?

Phone

Responsible Party:

Name of Person Responsible for this Account

Relationship to Patient

Address

City/State/Zip

Home Phone

Work Phone

Cell Phone

Drivers License #

Date of Birth

Social Security #

Is this Person Currently a Patient in our Office

Primary Insurance Information:

Name of Insured

Relationship to Patient

Date of Birth

Social Security #

Employer

Union or Local #

Address

City/State/Zip

Work Phone

Insurance Company

Group #

Policy/ID #

Ins Company Address

City/State/Zip

Ins Company Phone

Do you have any additional Insurance

If YES, please complete the following

Secondary Insurance Information:

Name of Insured

Relationship to Patient

Date of Birth

Social Security #

Employer

Union or Local #

Address

City/State/Zip

Work Phone

Insurance Company

Group #

Policy/ID #

Ins Company Address

City/State/Zip

Ins Company Phone

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

I Agree *

0 + 1 = ? Please prove that you are human by solving the equation *

Downloadable Forms

Patient info

Responsible Party:

Primary Insurance Information:

Secondary Insurance Information:

Organizations

Gregg O. Wilcox, DMD is a proud member of the following organizations:

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