The University of Texas Health Science Center at San Antonio Dental School

Please Print

Social Security #:

Name of Patient:

Date of Birth:

Sex:

F___   M ___

Ethnic Origin:

Age:

Marital Status:

Home Address:

City:

State:

Zip:

Home Phone:

Phone of Friend or Relative:

Business Address:

Business Phone:

Occupation:

Have you received treatment here previously?

Yes ___ No ___

IN CASE OF EMERGENCY PLEASE CALL:

1.

Telephone::

2.

Telephone:

ASSIGNMENT RECORD:

1.

Active:

Provider Name

Faculty Stamp (name, number, department) and signature or initials Date

ID Number:

This line Recall only

Recall:

Faculty Stamp (name, number, department) and signature or initials Date

CARE LEVEL 0 1 2 3 (circle one)

Cmplt

Trans

Disc:

Faculty Stamp (name, number, department) and signature or initials Date

2.

Active:

Provider Name

Faculty Stamp (name, number, department) and signature or initials Date

ID Number:

This line Recall only

Recall:

Faculty Stamp (name, number, department) and signature or initials Date

CARE LEVEL 0 1 2 3 (circle one)

Cmplt

Trans

Disc:

Faculty Stamp (name, number, department) and signature or initials Date

3.

Active:

Provider Name

Faculty Stamp (name, number, department) and signature or initials Date

ID Number:

This line Recall only

Recall:

Faculty Stamp (name, number, department) and signature or initials Date

CARE LEVEL 0 1 2 3 (circle one)

Cmplt

Trans

Disc:

Faculty Stamp (name, number, department) and signature or initials Date

4.

Active:

Provider Name

Faculty Stamp (name, number, department) and signature or initials Date

ID Number:

This line Recall only

Recall:

Faculty Stamp (name, number, department) and signature or initials Date

CARE LEVEL 0 1 2 3 (circle one)

Cmplt

Trans

Disc:

Faculty Stamp (name, number, department) and signature or initials Date

5.

Active:

Provider Name

Faculty Stamp (name, number, department) and signature or initials Date

ID Number:

This line Recall only

Recall:

Faculty Stamp (name, number, department) and signature or initials Date

CARE LEVEL 0 1 2 3 (circle one)

Cmplt

Trans

Disc:

Faculty Stamp (name, number, department) and signature or initials Date

Revised 5/1/01 1