4501 50th Street Lubbock, TX 79414
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.
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
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?
Who is responsible for paying this account?
Will there be dental insurance? What Kind?
Driver License Number
Social Security Number
Call or Email us
Get to know Dr. A.K. Johnson
View our galley