New Patient, Web form

RESPONSIBLE PARTY INFORMATION
Responsible Party’s Name:
Relationship:
Self, Father, Mother, Guardian, etc...
Responsible Party Phone Number
Please take pictures of the responsible party's ID or Driver License and UPLOAD here

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Name of other dependants under this plan

Please take pictures of BOTH sides of the primary insurance card and UPLOAD here

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Name of other dependants under this plan

Please take pictures of BOTH sides of the secondary insurance card and UPLOAD here:

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SIGNATURE FOR FRONT PAGE OF NEW PATIENT FORM
This New Patient registration form is submitted via a secured service. However, other unencrypted email, text messages, phone calls and voice mails are not a fully secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such communications that may be misdirected, disclosed to or intercepted by unauthorized third parties. By signing this document, I consent to and accept the risk in receiving information via email, text message, phone calls, and voice mails. I understand I can withdraw my consent at any time
Authorization:

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered.I authorize the use of this signature on all insurance submissions and for the dentist to release all necessary information to secure the payment of benefits.I understand that I am financially responsible for all charges whether or not paid by insurance (Please note that payment is due in full on day of treatment unless prior payment arrangements have already been made)
Patient or Parent/Guardian’s Signature:

Clear
Date:

MonthDayYear
Date

Page 2 of New Patient registration form

Please review patient Name and click Next to proceed
Patient Name

First NameLast Name
Middle Name

	Yes	No
AIDS/HIV+
ADD/ADHD
Asthma
Autism
Bleeding Problems
Blood Disease
Blood Transfusion
Cancer
Cerebral Palsy
Chemotherapy
Chronic Respiratory Infections
Cleft Lip/Palate

	Yes	No
Premature Birth
Radiation Therapy
Rheumatic fever
Shortness of Breath
Sickle Cell Trait/Disease
Speech Problems
Tumor
Thyroid Conditions
Tuberculosis
NOT up to date on immunizations

San Jose Dental Specialists