Patient Registration

Please complete the following confidential information:

This registration is for:
Name:
Prefers to be called by:
Address:
Home Phone:
-
Cell Phone:
-
E-mail:
Birthdate:
 / 
 / 
Age:
Sex:
Marital Status:
School:
Grade:

DENTAL INSURANCE INFORMATION

Insurance Company:
Group No:
Employer Name:
Insured's Name:
Insured DOB:
 / 
 / 
Relationship to Patient:
Insured's ID No.:

SECONDARY CARRIER INFORMATION

Secondary Ins Company:
Secondary Group No:
Secondary Employer Name:
Secondary Insured's Name:
Secondary Insured DOB:
 / 
 / 
Secondary's Relationship to Patient:
Secondary Insured's ID No.:

GETTING TO KNOW YOU

Is another member of your family or relative a patient at our office?:
Relationship:

YOU WERE REFERRED TO US BY

Referrer's Name:

PERSON TO CONACT FOR EMERGENCY

Contact Name:
Contact Cell #:
-
Contact Home #:
-
Contact Address:

ACCOUNT INFORMATION

Name of Person Financially Responsible for Account:
Relationship To Patient:
Person's Address:
Person's Phone:
-

YOU

Your Name:
Occupation:
Employer's Name:
Your Address:
Your Phone:
-

YOUR SPOUSE

Spouse's Name:
Spouse's Occupation:
Spouse's Employer:
Spouse's Address:
Spouse's Phone:
-

CONSENT FOR TREATMENT

  1. Hereby authorized doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient’s dental needs.
  2. Upon such diagnosis, I authorized doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
  3. I agreed to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for complete recital of any possible complications.
  4. I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
  5. Agreed to be responsible for payment of all services rendered on my behalf or my dependents. Understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added it to my account. If required, I also understand a check of my credit history may be made.
  6. Cell Phone: I consent to the dental practice using my cell phone number to call or text regarding appointments and to call regarding treatment, insurance, and my account. Understand that I can withdraw my consent at any time. My cell phone number is included below.
Cell Phone Consent:
Cell Phone #:
-
Preference: (Choose one or both):

DIGITAL SIGNATURE

Patient or Responsible Party's Name:
Relationship to Patient (if applicable):
Date:
Spam Verification: