Registration Form

Please complete the following section about the patient:

Name

Nickname

Date of Birth

Social Security Number

Mailing Address

State

Zip

Home Phone

Work Phone

May we call to confirm appointments?

Yes No

Please complete the following section if you have dental insurance:

Name of the Insured

Date of Birth

Where does insured work?

SS#

Insured's Mailing Address if Different than Patient's

State

Zip

Insured's Home Phone

Insured's Work Phone

May we call work to confirm appointments?

Yes No

Name of Insurance Company

Cert/Policy/Group #

Patient's Relationship to Insured

Self Spouse Child Other

Have you used your dental insurance in the last 12 months?

Yes No

Please complete the following section if you have medical insurance:

Name of the Insured

Date of Birth

Where does insured work?

SS#

Name of Insurance Company

Cert/Policy/Group #

Name of Physician

Phone

Patient's Relationship to Insured

Self Spouse Child Other

Please complete the following section if the patient is not financially responsible or insured:

Name of Person to be Billed

Date of Birth

Mailing Address

State

Zip

Social Security Number

Relationship to Patient

Home Phone

Work Phone

We would like to know:

Whom should we notify in case of emergency?

Relationship to Patient

Phone

Whom may we thank for referring you?