Patient Registration
This information is necessary for our file and will be considered confidential.
Date:
*
-
Month
-
Day
Year
Name:
*
First Name
Last Name
Prefers to be called:
*
Gender:
*
Male
Female
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone number:
*
Please enter a valid phone number.
Cell phone number:
Please enter a valid phone number.
Email address:
example@example.com
Marital Status:
*
Married
Single
Divorced
Separated
Widowed
Birthdate:
*
-
Month
-
Day
Year
Social Security Number:
Your Employer:
Occupation:
Business Phone:
Please enter a valid phone number.
Spouse's Name:
First Name
Last Name
Whom may we thank for referring you to our office?
*
Financial Information
Person responsible for account:
*
First Name
Last Name
Relationship to patient:
*
Billing address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Primary Dental Insurance
Name of Insurance Company:
Group Number:
Insured's ID Number:
Employer's Name:
Insured's Name:
First Name
Last Name
Insured's Birthdate:
-
Month
-
Day
Year
Date
Insured's relationship to patient:
Do you have secondary dental insurance?
*
Yes
No
Please attach front and back copies of primary and secondary insurance cards (if applicable)
Browse Files
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of
Consent for Treatment
I hereby authorize 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
Patient First Name
*
Patient Last Name
*
dental needs.
Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
I agree 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 a complete recital of any possible complications.
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.
I agree to be responsible for payment of all services rendered on my behalf or my dependents. I 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 to my account. If required, I also understand a check or my credit history may be made.
Cell Phone: I consent to the dental practice using my cell phone number to contact me as specified below regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time. My cell phone number is
Area Code
*
Phone Number
*
I prefer the following contact method:
*
Call
Text
Call and Text
Patient's Signature
*
Use your mouse to sign by holding down the button continuously with your index finger and signing/moving the mouse in the signature box.
Clear
Parent/Responsible Party Signature:
*
Use your mouse to sign by holding down the button continuously with your index finger and signing/moving the mouse in the signature box.
Clear
Relationship to patient:
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: