Patient Registration Form

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us. We will be happy to help.

PATIENT INFORMATION

Minor

Single

Married

Divorced

Widowed

Separated

Name

Date of Birth

Address

Apt#

City

State

Zip

Cell Phone

Home Phone

Work Phone

Email address

Referred to our office by

EMERGENCY CONTACT

Name of relative of patient and their relationship

Phone #

RESPONSIBLE PARTY INFORMATION

Name of Responsible Party (self or guardian)

Social Security #

Address

Apt#

City

State

Zip

Occupation

Employer's

Phone Number

DENTAL INSURANCE INFORMATION

Insurance company

Insured Name

Insured DOB

Insured SS#

Relationship to Patient

Subscriber ID #

Group #

Employer

SECONDARY INSURANCE INFORMATION

Insurance Company

Insurance Name

Insured DOB

Insured SS#

Relationship to Patient

Subscriber ID #

Group #

Employer

HIPAA RELEASE OF INFORMATION AUTHORIZATION

have read and understand the HIPAA agreement given to me. I hereby authorize Broadway Smiles and its affiliates, its employees and agents to release to my personal health information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number. I authorized any personal health information or other information may be released to:

Name of Person or Persons

Relationship

AUTHORIZATION

I, hereby authorize payment directly to the Dental Office for the group’s insurance benefits otherwise payable to me. I understand that I am responsible for all the costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostics, photographic, and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/ medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/ medical histories and other information about my dental treatment to the third party payers and/or other health professionals.

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 or Parent / Guardian if Minor

Date

Your information will be encrypted.