Patient Registration Form

Amazing Smile Family Dental Center

Please correct the errors described below.

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 completely confidential. Thank you.

Please list others authorized to discuss your dental account

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

Primary Insurance Information

Secondary Insurance Information

I hereby authorize and request the performance of dental services for myself by Dr. Fredrick Vega and staff. I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by Dr. Vega and staff for diagnostic purposes or dental treatment. I understand and acknowledge that I am financially responsible for the services rendered, regardless of insurance coverage.

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

Your information will be encrypted.

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