chatsworthsedationdentist-PATIENT REGISTRATION

PATIENT REGISTRATION
Welcome to our office! We know that you will be pleased with your care. Prior to beginning treatment, the following information is necessary. Please complete this form fully and PRINT legibly. All information will be held in strict confidence. Thank you for making us your happy dental home!
How did you hear about us? (Whom may we thank for your referral?)
PATIENT INFORMATION
Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Birthday

MonthDayYear
Date
Age
Sex
Drivers Lic. No
Employer
Work Phone
Please enter a valid phone number.
Extension
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Pager
Please enter a valid phone number.
Occupation
Name of Spouse
Spouse’s Employer
Phone Number
Please enter a valid phone number.
College Student:

Name of School

Street Address Line 2

CityState / Province

Postal / Zip Code
If patient is a minor, may we treat him or her in your absence should they come in for treatment at a regular appointment and you are unable to accompany them to the office?

YesNo
No treatment other than that for which the minor is scheduled shall be performed at that visit if you are not present.
Person to contact in case of an emergency:
Name
Relationship
Phone Number
Please enter a valid phone number.
FOR PATIENTS COVERED BY DENTAL INSURANCE
Subscriber’s Name
Birthdate:

MonthDayYear
Date
Home Phone:
Please enter a valid phone number.
Employer
Work Phone:
Please enter a valid phone number.
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group / Policy Number
Social Security Number
Patient’s Relationship to Subscriber:

SelfSpouseDependent
Have you used this dental insurance previously?

YesNo
Are you covered by more than one dental insurance?

YesNo
SECONDARY INSURANCE

If yes, please complete the next
Subscriber’s Name
Birthdate:

MonthDayYear
Date
Home Phone:
Please enter a valid phone number.
Employer
Work Phone:
Please enter a valid phone number.
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group / Policy Number
Social Security Number
Patient’s Relationship to Subscriber:

SelfSpouseDependent
CONSENT

This is to certify that I, the undersigned, consent to the performing of whatever dental services and/or surgical procedures may be decided upon to be necessary or advisable, and to the use of local anesthetic as may be deemed advisable by the dentist. I hereby authorize my dentist to release any and all dental and medical information to the above-named insurance carrier(s) for the purposes of claims administration and evaluation, utilization review and financial audit. This authorization remains valid and effective from the date of signing until revoked in writing. I hereby authorize my Insurance Carrier to pay directly to the within-named dentist(s) the dental benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by insurance. I acknowledge the office policy that I must give forty-eight hours notice, during business hours, to change or cancel an appointment. Failure to do so may result in a charge to my account.
Signature

Patient (Parent or Guardian for minor child) Clear
Date

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION

PATIENT INFORMATION

Person to contact in case of an emergency:

FOR PATIENTS COVERED BY DENTAL INSURANCE

SECONDARY INSURANCE