Dr. James A. Wells, D.D.S., Family & Cosmetic Dentistry Charolotte, NC
Home
Services
Invisalign
Zoom
Intraoral Camera
Ultra Suction
Same Day Crown
Periodontal Therapy
Digital X-rays
Products
Staff
FAQ
Contact
Forms
Patient Information
Patient Medical History
Assignment of Benefits
Financial Policy
Acknowledgement of Receipt of Privacy Practices
Authorization for Release of Information
Print Form
Patient Information
Date:
Name:
Birthdate:
Home Phone:
Cell Phone:
Address:
City:
State:
Zip:
Email:
If student, Name of School/College:
Full Time/Part Time:
Patient’s or Parents Employer:
Work Phone:
Spouse or Parent’s Name:
Employer:
Phone:
Referred By:
Emergency Contact:
Phone:
Responsible Party
Name of Person Responsible for this Account:
Relationship to Patient:
Address:
Home Phone:
Birthdate:
Employer:
Work Phone:
Insurance Information
Name of Insured:
Relationship to Patient :
Birthdate:
Name of Employer:
Work Phone:
Employer Address:
City:
State:
Zip:
Insurance Company:
Group No:
Policy/ID #:
Ins. Co. Address:
City:
State:
Zip: