Patient Registration

First Name

Last Name

Middle Initial

Preferred Name

Patient is

Policy Holder

Responsible Party

Neither

Responsible Party (if someone other than the patient)

First Name

Last Name

Middle Initial

Address

Address 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

I allow Michelle B. Deutch Family Dentistry to send text messages and or emails to my personal cell phone.

Yes No

Date of Birth

Social Security #

Drivers License

Responsible Party is

Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Policy Holder

Patient Information

Address

Address 2

City

State

Zip

Home Phone

Work Phone

Cell Phone

I allow Michelle B. Deutch Family Dentistry to send text messages and or emails to my personal cell phone.

Yes No

Sex

Male Female

Marital Status

Single Married Divorced Seperated Widowed

Birth Date

Age

Social Security

Drivers License

Email Address (For Patient Confirmation of appointments and specials)

Accepts Text Message

Previous Dentist

Phone Number

Preferred Pharmacy

Phone Number

Employment Status

Full Time Part Time Retired

Student Status

Full Time

Part Time

Employer

Occupation

Employer Address

Insurance Information

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.

Signature

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