Brushy Mountain Dental 1401 Willow Lane N. Wilkesboro, NC 28659 • 336.667.9991

New Patient Form

First Name
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Last Name
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Email
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Street Address
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City
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State
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ZIP Code
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Sex
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Date of Birth
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Phone
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Marital Status
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Employer
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Work Phone
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Insurance Information
Do you have insurance?
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Are you self-insured?
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Insured Full Name
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Insured Date of Birth
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Insured Employer
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Additional Information
Emergency Contact Name
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Emergency Contact Phone
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Emergency Contact Relation to Patient
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Referring Dentist
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Is anyone in your household a current patient at Brushy Mountain Dental?
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If so, please share the patient's name:
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