Patient Registration Form

Patient Registration Form
Patient's Legal Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Social Security Number*
Prefer to Be Called
Home Phone #
Cell Phone #
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Marital Status*

SingleMarriedWidowedDivorcedUnder Age 18
Patient/Guardian's Employer*
Occupation
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Spouse's Name

First NameMiddle NameLast Name
Spouse's Employer
Spouse's Occupation
Spouse's Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Work Phone Number
Other Family Members That Are Patients Here
Who Can We Thank For Referring You To Our Office?
Emergency Contact Information

Person We May Contact in Case of An Emergency (Other Than Your Family Home)
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Request for Confidential Communication

As My Dental Care Provider, You May Do The Following With My Permission*

	Yes	No
Contact Me At Home
Contact Me Via Cell Phone
Contact Me At Work
Contact Me Via Email
Leave Messages On My Home Voicemail/Answering Machine
Leave Messages On My Cell Phone Voicemail
Leave Messages On My Work Voicemail/Answering Machine

Insurance and Financial Information
Insurance Coverage*

YesNo
Insurance Company Name*
Insurance Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number*
Subscriber's Name*

First NameLast Name
Patient's Relationship to Subscriber*

SelfSpouseDependent
Subscriber's Birthday*

MonthDayYear
Date
Subscriber's SSN/ID#*
Group/Program Number*
Employer (If Different from Above)
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Information
You May Discuss My Healthcare With:
Health Care Providers*

YesNo
Insurance Companies*

YesNo
Others (Enter Below)
Confirmations
Do You Prefer a Confirmation Call?*

No, It is unnecessaryYes, It is a helpful reminder
Assignment & Release
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due to and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations, and/or presentations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Registration Form

Emergency Contact Information

Request for Confidential Communication

Insurance and Financial Information

Release Information

Confirmations

Assignment & Release