{"content":[{"text":"Patient Information:","bbox":{"left":0.442549,"top":0.021,"width":0.17358800000000002,"height":0.020985}},{"text":"Date: ________________","bbox":{"left":0.735294,"top":0.038727,"width":0.17029799999999995,"height":0.016776}},{"text":"Home Phone: _________________________","bbox":{"left":0.088235,"top":0.08185,"width":0.327822,"height":0.018577999999999997}},{"text":"Cell Number: __________________________","bbox":{"left":0.599412,"top":0.083273,"width":0.30578700000000014,"height":0.016776}},{"text":"Name: _____________________________________________ SSN #___________________________________","bbox":{"left":0.088235,"top":0.11382,"width":0.822358,"height":0.01857800000000001}},{"text":"Address: _____________________________________City:_____________ State: ________ Zip Code: _________","bbox":{"left":0.088235,"top":0.14579,"width":0.838026,"height":0.01857800000000001}},{"text":"Sex: M __ F __","bbox":{"left":0.088235,"top":0.177759,"width":0.12096300000000003,"height":0.01857800000000001}},{"text":"Birthday: _______________","bbox":{"left":0.264704,"top":0.177759,"width":0.20725,"height":0.01857800000000001}},{"text":"Minor__ Single___ Married___","bbox":{"left":0.513528,"top":0.177759,"width":0.22979799999999995,"height":0.01857800000000001}},{"text":"Parent/Patient Employer: ______________________________________Work Number:______________________","bbox":{"left":0.088235,"top":0.209729,"width":0.8342980000000001,"height":0.01857800000000001}},{"text":"Patient email address:","bbox":{"left":0.088235,"top":0.241699,"width":0.15775899999999998,"height":0.018577999999999983}},{"text":"__________________________________________________","bbox":{"left":0.255098,"top":0.241699,"width":0.44919800000000004,"height":0.018577999999999983}},{"text":"Whom may we thank for referring you to our office: ________________________________________________","bbox":{"left":0.088235,"top":0.273517,"width":0.8127380000000001,"height":0.018577999999999983}},{"text":"Emergency Information: \n Please list two people to contact in case of an emergency. One CANNOT live with you, it does not have to be a relative and the \n other can be your spouse/significant other: \n Name: __________________________________________ Home Phone: ___________________________","bbox":{"left":0.088235,"top":0.301568,"width":0.878618,"height":0.07340599999999997}},{"text":"Name: ___________________________________________ Cell Number___________________________ \n Responsible Party: (The person paying on the account. Not your insurance.)","bbox":{"left":0.088235,"top":0.388214,"width":0.779597,"height":0.046989999999999976}},{"text":"Name: ___________________________Birth Date: _____________ SSN # ___________________________","bbox":{"left":0.088235,"top":0.447759,"width":0.7949070000000001,"height":0.018577999999999983}},{"text":"Address: _____________________________ City: ____________________ State: _______ Zip Code: ________","bbox":{"left":0.088235,"top":0.479729,"width":0.820009,"height":0.018577999999999983}},{"text":"Employer: _______________________________________","bbox":{"left":0.088235,"top":0.511699,"width":0.4309779999999999,"height":0.018577999999999983}},{"text":"Work number: ___________________________","bbox":{"left":0.546083,"top":0.511699,"width":0.35234299999999996,"height":0.018577999999999983}},{"text":"Has anyone in your family been in our office? __________Relationship:_____________________________","bbox":{"left":0.088235,"top":0.543794,"width":0.807446,"height":0.019289}},{"text":"Insurance Information:","bbox":{"left":0.088235,"top":0.575763,"width":0.18129800000000001,"height":0.019289}},{"text":"Insured Name: ___________________________Relationship to Patient: ___________ Birth date:______________","bbox":{"left":0.088235,"top":0.607456,"width":0.832164,"height":0.018577999999999983}},{"text":"Insured Employed by: __________________________________________ Phone: _________________________","bbox":{"left":0.088235,"top":0.639426,"width":0.8253030000000001,"height":0.018577999999999983}},{"text":"Insurance Company _______________________________________ Phone: ____________________________","bbox":{"left":0.088235,"top":0.671396,"width":0.809798,"height":0.018577999999999983}},{"text":"Group # __________________ Subscriber/ID # ______________________","bbox":{"left":0.088235,"top":0.703365,"width":0.546855,"height":0.018577999999999983}},{"text":"Is the patient covered by a secondary dental insurance: Y ___ N __?","bbox":{"left":0.088235,"top":0.735335,"width":0.49623899999999993,"height":0.018577999999999983}},{"text":"Insured Name: ______________________________Soc. Sec. #________________________ Birth Date:_______","bbox":{"left":0.088235,"top":0.767153,"width":0.8239310000000001,"height":0.018577999999999983}},{"text":"Insurance company __________________________________ phone number # __________________________","bbox":{"left":0.088235,"top":0.799123,"width":0.8096090000000001,"height":0.018577999999999983}},{"text":"Insured’s Employer: ______________________________________Business Phone: _______________________","bbox":{"left":0.088235,"top":0.831093,"width":0.822944,"height":0.018577999999999983}},{"text":"Group # __________________ Subscriber/ID # _______________________","bbox":{"left":0.088235,"top":0.863062,"width":0.5558660000000001,"height":0.018577999999999983}},{"text":"Appointment Policy:","bbox":{"left":0.088235,"top":0.895157,"width":0.159337,"height":0.019289}},{"text":"Your appointment time has been reserved especially for you. \n charge by giving us at least 24-hour notice.","bbox":{"left":0.088235,"top":0.928271,"width":0.43606799999999996,"height":0.03306500000000012}},{"text":"If you cannot keep your appointment you can avoid a $50.00","bbox":{"left":0.533148,"top":0.927978,"width":0.437026,"height":0.01804899999999998}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}