Patient Registration Form

Please correct the errors described below.

Patient Information (CONFIDENTIAL)

Responsible Party

Insurance Information

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Patient Medical History

8. Do you have or have you had any of the following?

9. Are you allergic to or have you had any reactions to the following?

11. Women Only:

Patient Dental History

7. Have you ever experienced any of the following problems in your jaw?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third-party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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