PATIENT INFORMATION FORM

JR MILLINGTON DENTISTRY

JOHN R. MILLINGTON, JR. DMD, LLC

Patient information
Name *
Name
Birthdate *
Birthdate
Street Address *
Street Address
Home Phone
Home Phone
Cell Phone *
Cell Phone
Business Phone
Business Phone
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
How did you hear about us?
Medical History (Do yo have or have you had any of the following
Are you allergic to:
Are you currently being treated by a physician *
Primary Insurance information
Do you have dental insurance?
Date of Birth
Date of Birth
Employer Phone
Employer Phone
Secondary insurance information
Only if applicable
Do you have secondary dental insurance?
Date of Birth
Date of Birth
Employer Phone Number
Employer Phone Number