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L. Wes Turnage, Jr. DMD Patient Registration

Patient Information

Name

Preferred Name

Street

City

State

Zip

Gender

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Marital Status

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Phone

Social Security

E-Mail

Patient Employment Information

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Zip

Spouse Information

Spouse's Name

Social Security #

Employer Name

Position

Address

City

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Zip

Responsible Party Information

Responsible Party

Relationship to Patient

Street

City

State

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Home Phone

Drivers License #

Social Security #

Employer's Name

Employer's Phone

Employer's Street

Employer's City

Employer's State

Employer's Zip

Primary Insurance

Insurance Company

Group Number

Street

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Zip

Name of Insured

Insured's ID#

Insured's Date of Birth

Secondary Insurance

Insurance Company

Group Number

Street

City

State

Zip

Name of Insured

Insured's ID#

Insured's Date of Birth

Injury/Accident/Other

Is this the result of an accident or injury?

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Is this the result of an accident or injury?

Work Related
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If Other, please explain

Date of Injury

Attorney, if any

Workers Comp. Carrier/Name

Phone #

Miscellaneous Information

Whom may we thank for referring you?

Emergency Contact Name

Emergency Phone #

Nearest Relative's Name (not living with you)

Nearest Relative's Phone # (not living with you)

Family Members or Friends seen by us

Patient Signature (or Guardian if patient is a minor)

Wes Turnage

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L. Wes Turnage, Jr., DMD909 N. Limestone StreetGaffney, SC 29340P: 864-489-4708 • F: 864-489-3577contact@drturnage.com

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