Fillable Patient Information Male Female Transgender

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Patient Information Male Female Transgender

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v.2017.6.21 Willamette Dental Group, P.C. Page 1 of 1
Patient Information
Name (Last, First, Middle Initial)
Preferred Name
Address
City, State, Zip
Email Address
Gender
Male Female Transgender
Mobile Phone Number
Preferred Contact Method (Please check one)*
Email Text Phone
*You’ll receive messages with important information from your dental team about your appointments and treatment through your preferred
contact method.
Emergency Contact
Name Relationship
Phone
Address
My Race / Ethnicity Identification Is
(Please Check All That Apply):
My Language Preference Is:
Asian
English
Black or African American
Spanish
Native Hawaiian or Other Pacific Islander
Russian
Hispanic or Latino
Chinese
American Indian or Alaska Native
Other ___________________________
White/Caucasian
Other (not listed)
Decline to Answer
*This information helps us ensure that we are providing the highest quality of care for our patients. Studies have shown that racial/ethnic backgrounds may impact our patients’
oral health risk for certain diseases. Recording patient data regarding race and ethnicity will allow Willamette Dental Group to better understand and meet our patients’ oral
health needs. As well, this information is not given away, sold, or used for anything other than Willamette Dental Group business.
Preferred Pharmacy & Physician
Pharmacy Name Pharmacy Phone Number
Pharmacy Address
Physician Name Physician Phone Number
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Patient Information Male Female Transgender

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Completed 20 September 2021

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