Lubbock Texas DentistDr. Andrew K. Johnson DDS, PC
 

Call us: 806.792.9811

4501 50th Street Lubbock, TX 79414

Personal Information

This personal infromation is requested to enable us to give you the most consideration of your time and feelings. This information is of course confidential.

Thank You.

Are you aware of any particular dental problem?  Yes No

If yes expalin:

How long has it been since you last visited the dentist?

What was done for you at that time?

Patient Name
Age


 Single Married Divorced Window Student

Date of Birth

Home address
City


Home Phone
Zip Code


Cell Phone

What is your occupation?

For what company do you work?
Phone


IF MARRIED, OCCUPATION OF YOUR HUSBAND OR WIFE?

For what company does your husband ( or wife ) work?

Phone
Ext.


Referred by

Who is responsible for paying this account?

Will there be dental insurance?
What Kind?


Driver License Number

Social Security Number

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