Registration Form

This personal information is requested to enable us to give you the most consideration of your time and feelings. It is important to have complete answers so that we may give you the personal attention you deserve. This information is kept completely confidential.

Last Name

First Name

Middle Initial

Date of Birth

Gender

S.S. Number

Home Phone Number

Cell Phone Number

Home Address

City

State

Zip

Mailing Address (if different from above)

Email address

Confirmation Text

Yes No

Employer

Work Phone Number

If married, what is your spouse's name?

Spouse's Date of Birth

Spouse's S.S. Number

Spouse's Employer

Spouse's Work Number

ARE YOU EXPERIENCING ANY DENTAL PROBLEMS AT THIS TIME? IF SO, WHAT?

How long has it been since your last dental visit?

What was done then?

How did you hear about us?

DO YOU HAVE DENTAL INSURANCE?

To obtain maximum dental benefits for our insured patients, we have our staff specifically trained to do just that. In order get your full complete benefits, we will need the following information:

Insurance Carrier

Group #

Subscriber ID

Phone

Subscriber Name

Date of Birth

Social Security Number of Subscriber

I hereby authorize and request the performance of dental services for myself by the staff of Rodney G. Sigua, DDS, MAGD, PLLC.

I also give my consent to any advisable and necessary dental procedures, medications or anesthetics to be administered by our staff for diagnostic purposes or dental treatment.

I understand and acknowledge that I am financially responsible for the services rendered, regardless of insurance coverage.

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

Date

Your information will be encrypted.