Patient Registration Form

Today's Date

PATIENT REGISTRATION

Patient Name

Nick Name

Birthdate

Address

City

State

Zip

Phone

Employer

Business Address

City

State

Zip

Phone

Years Employed

Soc. Sec. No.

Spouse Name

No. of Dependents

Spouse's Soc. Sec. No.

Spouse's Employer

Referred By

Emergency Contact Name

Phone

PERSON RESPONSIBLE FOR THIS ACCOUNT

Responsible Party's Name

Relationship to Patient

Street Address

Phone

Employer

Years Employed

Soc. Sec. No.

Business Address

City

State

Zip

Phone

FOR PATIENTS COVERED BY INSURANCE

Subscriber's Name

Employee I.D #

Birthdate

Soc. Sec. No.

Employer

Business Address

City

State

Zip

Insurance Co.

Group No.

Max. Benefit S

Benefit Year

Are you covered under more than one Dental Plan? (If Yes, Please Fill Out Below)

Yes No

SECONDARY INSURANCE

Subscriber's Name

Employee I.D. #

Birthdate

Soc. Sec. No.

Employer

Group No.

Insurane Co.

Relationship to Patient

FOR OFFICE USE ONLY

Primary Subscriber Name

Family Member No.

Emp No.

Secondary Subscriber Name

Family Member No.

Emp No.

Doctor

Medical Message

No Message

See Medical

Pre-medicate

See Medical and Pre-medicate

Allergies

The above information is accurate and complete and to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

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 Responsible Party

Date

Your information will be encrypted.

Patient Registration Form