loomisfamilydentist.com - PATIENT REGISTRATION

PATIENT REGISTRATION
Date

MonthDayYear
Date
Patient Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment Number:
GENDER:

MALEFEMALE
Age:
Birthdate:

MonthDayYear
Date
Marital Status:

SingleMarriedChildOther
Patient SS#:
Occupation:
Employer:
Email Address:
example@example.com
Whom may we thank for referring you?
Dental Insurance
Who is responsible for this account
Relationship to Patient
Insurance Co.
Group #
Is patient covered by additional insurance?

YesNo
Subscriber's Name:
Birthdate

MonthDayYear
Date
SS#
Relationship to Patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have insurance coverage with Type a label and assigned directly to Dr. Navneet Kaur all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature

Clear
Relationship
Date

MonthDayYear
Date
Phone Numbers
Patient Legal Guardian
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext
Cell/Mobile
Please enter a valid phone number.
Spouse's Work
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT (Specify someone who doesn't live in your household)
Name
Relationship
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Should be Empty:

PATIENT REGISTRATION

Dental Insurance

Phone Numbers