New Patient Registration

Name

Today's Date

Address

City

State

Zip Code

Home Phone No.

Work Phone No.

Cell Phone No.

Date of Birth

Email address

Referred By: (Please ask about our Care Enough to Share Program )

RESPONSIBLE PARTY INFORMATION

Name of Responsible Party

Social Security No.

Address (if different that above)

Occupation

Employer

Work Phone No.

How would you like to pay for your portion of the provided services?

Cash Check Credit Card

DENTAL INSURANCE

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SECONDARY DENTAL INSURANCE

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PATIENT DENTAL HISTORY

Date of last dental visit

Last Dental Cleaning

Last Full Mouth X-Rays

Which of these dental-aids do you use?

Sonicare

Braun

Toothpicks

Bleach Kits

Floss

Do you have active dental problems now?

Gum Disease

Bleeding Gums

Broken Teeth

Decay

PATIENT MEDICAL HISTORY

If yes, Please Explain

Name of Family Physician

Do you have any health problems that need further clarification?

Please list all medications that you are currently taking

FINANCIAL AGREEMENT

This office participates with CareFirst, Delta Dental, and Dents Quest Choice. Patients who carry dental insurance understand that all services furnished are charged directly to the patient and that he or she is personally responsible for payment for all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance. We offer a 5% discount to our patients who pay their treatment plans up front in full.

A service charge of 1 1/2 per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. If the account is not cleared, the account will be turned over to collections and a 30% collection fee will be added.

Any checks returned to the office are subject to an additional fee of $25.00. If for any reason you are unable to keep your appointment, 24 hours notice must be given to avoid the 51.00 broken appointment fee.

I have read the above conditions of treatment and payment and agree to their content. All the above answers and information provided are true and correct. If I have any change in my health I will notify the doctors on my next appointment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of patient, parent, or guardian

Date

Relationship to patient

Signature of guarantor of payment

Date

Relationship to patient

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Phone Number

Signature

Your information will be encrypted.