Patient Registration Form

Name

Birth Date

Sex

Male Female

Marital Status

Married Single Minor

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Preferred telephone number to receive call from 46 Dental

Home Cell Work

Email address

In case of Minor (Child)

Is parents

Divorced or Separated

Who has custody of the child?

Name of Parent/ Guardian/ Responsible Party

If Student

Name of School/College

City

State

Full time

Part time

Insurance Information

Primary Insurance

Name of Insured

Relationship to patient

Birth Date

SS #

Name of Insurance Company

Group #

Subscriber Ins. ID #

Mailing address of insurance company

City

State

Zip

Name of Employer

Address of employer

City

State

Zip

Do you have any additional insurance?

Yes No

Secondary Insurance Information

Name of Insured

Relationship to patient

Birth Date

SS #

Name of Insurance Company

Group #

Subscriber Ins. ID #

Mailing address of insurance company

City

State

Zip

Name of Employer

Address of employer

City

State

Zip

For your convenience, we offer the following methods of payments

Cash Personal Check CC Visa MasterCard Other

Payment in full with each appointment.

I wish to discuss dental office financial policy.

Person to Contact In Case of Emergency

Name

Relation

Address

City

State

Zip

Tel #

Cell #

Has any member of your family treated in our office?

Yes No

Whom may we thank for referring you to our office?

Authorization & Release

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all the cost of dental treatment (including deductible, co-insurance as well as treatment cost not covered by my insurance company). The information provided is correct to the best of my knowledge. I hereby authorize release of my medical/dental histories, examination, diagnosis, and record of treatment rendered including x-rays to third party payor (Ins. Co.) and/or other health professionals by any method including electronic transfer.

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 Parents/Guardian if minor)

Date

Your information will be encrypted.