New Patient Registration Form

DENTAL INSURANCE INFORMATION

If you have dental insurance that may need verification, please provide the requested information below as accurate as possible. A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the patient’s account and the patient or person responsible for the account is responsible for payment of all fees incurred. We will gladly assist you in submitting insurance claims pertaining to any charge for care in our office.
PRIMARY INSURANCE INFORMATION
Insured's Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship to patient
Employer
Insurance Company Name
If Delta Dental, what State?
Effective Date

Month Day Year
Date
Group Number
Subscriber ID/ Membership ID/ Social Security Number
Insurance Company Address
Insurance Company Phone
Do you have dual coverage?

Yes. If yes, please complete the information for the second insurance carrier below. No
SECONDARY INSURANCE INFORMATION
Insured's Name

First Name Last Name
Date of Birth

Month Day Year
Date
Relationship to patient
Employer
Insurance Company Name
If Delta Dental, what State?
Effective Date

Month Day Year
Date
Group Number
Subscriber ID/ Membership ID/ Social Security Number
Insurance Company Address
Insurance Company Phone

I understand that I am responsible for payment of services rendered and also responsible for paying any copayments and deductibles that my insurance does not cover. In the event of a default on agreed upon payment arrangements, I am responsible for reasonable collection costs.

I have truthfully answered all of the above questions and agree to inform Kind Orthodontics of any changes in my medical or dental history. In addition, I authorize Dr. Emerald Nguyen or Dr. Nga Hoang to perform a complete orthodontic evaluation.
Signature (Parent/Responsible Party if minor) *

Clear
Date *

Month Day Year
Date
Doctor Signature (medical history reviewed)
Date

Month Day Year
Date
Should be Empty:

NEW PATIENT REGISTRATION