Welcome! We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health. Patient Name:* First Last SS# (21 & up) Sex (Circle One)* Female Male Age* Birth Date* MM slash DD slash YYYY Address* City* State* Zip* Cell Phone*Alternate Phone (Work / Cell)E-Mail* Marital Status* Single Married Widowed Separated