Dr. Nakatsuka Patient Registration

Patient Registration

This information is necessary for our file and will be considered confidential.
Date:*

MonthDayYear
Name: *

First NameLast Name
Prefers to be called:*
Gender:*

MaleFemale
Home Address:*

Street Address

Street Address Line 2

CityState / 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:*

MarriedSingleDivorcedSeparatedWidowed
Birthdate:*

MonthDayYear
Social Security Number:
Your Employer:
Occupation:
Business Phone:
Please enter a valid phone number.
Spouse's Name:

First NameLast Name
Whom may we thank for referring you to our office?*
Financial Information
Person responsible for account:*

First NameLast Name
Relationship to patient:*
Billing address:*

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Insured's Birthdate:

MonthDayYear
Date
Insured's relationship to patient:
Do you have secondary dental insurance?*

YesNo
Please attach front and back copies of primary and secondary insurance cards (if applicable)

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Cancelof
Consent for Treatment
1. 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.
2. 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.
3. 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.
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. 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.
6. 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:*

CallTextCall 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*

MonthDayYear
Should be Empty:

Patient Registration

Financial Information

Primary Dental Insurance

Consent for Treatment