Patient Registration & Treatment

Date

Home Phone No.

Cell Phone No.

PATIENT INFORMATION

Last Name / First Name / Middle

SS / HIC / Patient ID No.

Address

Email address

City

State

Zip

Age

If Partnered, For how many years?

Patient Employer / School

Employer / School Phone

Whom may we thank for referring you?

In case of emergency who should be notified?

Phone No.

PRIMARY INSURANCE

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ADDITIONAL INSURANCE

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DENTAL HISTORY

Reason for Today's Visit

Date of last dental care

Former Dentist

Date of last dental X-rays

Address

How often do you floss?

How often do you brush?

MEDICAL HISTORY

Physician's Name

Date of Last Visit

If yes, describe

If yes, give approximate dates

MEDICATIONS

ALLERGIES

AUTHORIZATION

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

Name of Insurance Company (ies)

Name of the Doctor

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I 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 for determining insurance benefits or the benefits payable for related services. This consent will end 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.

Signature of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

Your information will be encrypted.

Patient Registration & Treatment

Scott A. Terry, DDS