Registration Form

Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you.

We look forward to working with you in maintaining your dental health.

Patient Information

Date

Phone

Alt. Phone

Last Name

First Name

Middle Initial

Address

City

State

Zip

SSN

E-mail

Sex

Male Female

Birth date

Marital Status

Married Widowed Single Minor Separated Divorced

Responsible Party

Patient Employer/School

Occupation

Employer/School Phone

Whom may we thank for referring you?

In case of emergency, who should be notified?

Phone

Primary Dental Insurance

Insurer Info

Last Name, First Name Middle Initial

Relation to Patient

Birthdate

Soc. Sec. #

Phone

Insurance Company

Insurance Company Address

City

State

Zip

Insurer's Employer

Occupation

Business Phone

Group #

Member ID #

Names of other dependents covered under this plan

Add new names that are covered under this plan

Additional Dental Insurance

Is patient covered by additional insurance?

Yes No

Subscriber Name

Birthdate

Relation to Patient

Phone

Address (If different from patient's)

City

State

Zip

Subscriber Employed by

Business Phone

Insurance Company

Soc.Sec. #

Contract #

Group #

Subscriber #

Names of other dependents covered under this plan

Add new names that are covered under this plan

Dental History

Reason for Today's Visit

Date of last dental care

Former Dentist

Office Phone Number

How often do you floss?

How often do you brush?

Authorization

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Name of Insurance Company(ies) Dr.

All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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.

Name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

Your information will be encrypted.