Tenggren Dental New Patient Form

New Patient Form
How did you hear about our office?
Patient Registration
First Name:
Last Name:
Middle Initial:
Preferred Name:
Patient is:

Policy HolderResponsible Party
Responsible Party

(if someone other than patient)
First Name:
Last Name:
Middle Initial:
Address:
Address 2:
City:
State:
Zip Code:
Home Phone
Cell Phone
Work Phone
Ext.
Pager
Birth Date

MonthDayYear
Date
Social Security
Drivers Lic.
Responsible Party is also a Policy Holder for Patient | Primary Insurance Policy Holder | Secondary Insurance Policy Holder
Patient Information
Address:
Address 2:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Work Phone
Ext.
Pager
Social Security #
Sex:

MaleFemale
Martial Status
Birth Date

MonthDayYear
Date
Social Security
Drivers Lic.
Email
example@example.com
I would like to receive correspondences via e-mail
Other Phone
Employment Status

Full TimePart TimeRetired
Student Status

Full TimePart Time
Medicaid ID:
Pref. Dentist
Employer ID:
Pref. Pharmacy
Carrier ID:
Pref. Hyg.
Primary Insurance Information
Name of Insured
Relationship to Insured?
Insured Soc. Sec.:
Insured Birth Date:
Employer
Address:
Address 2:
City
State
Zip
Rem. Benefits:
Rem. Deduct:
Insurance Company:
Address:
Address 2:
City
State
Zip
Secondary Insurance Information
Name of Insured
Relationship to Insured?
Insured Soc. Sec.:
Insured Birth Date:
Employer
Address:
Address 2:
City
Rem. Benefits:
Insurance Company:
Address:
Address 2:
City
State
Zip

Financial Policy
Thank you for selecting us as your dental care provider. We are committed to the highest level of quality, preventive treatment. Outlined below is our financial policy. Please read it carefully and sign it before being seen by the doctor.
Our practice is committed to providing the best treatment for our patients, based on a diagnosis of what is needed to save and prevent further loss or damage to your gums or teeth. We charge fees that are usual and customary for our area. Our diagnosis will not be based on what your insurance company will cover, the amount of money you have left towards your maximum, or how economical the treatment will be. Again, it will be based on what is in the best interest of your dental and health care. Regardless of any insurance company’s arbitrary determination of what is usual and customary, you are responsible for payment.

Be aware that this is only an estimate. The actual amount could vary depending on what your insurance will cover or unexpected changes of treatment. You are ultimately responsible for any balance for services rendered. We cannot bill your insurance company unless you give us your insurance information. This information must be provided before treatment begins. Your insurance policy is a contract between your employer and your insurance begins. Your insurance policy is a contract between your employer and your insurance company. We are not a party to that agreement. Until your insurance company has paid their portion of services rendered, the unpaid balance will show on your monthly statement.
I have read, understand and agree to the above terms.
Print Patient Name:
Signature: (patient/parent/guardian)
Date
*If submitting via email, a signature will be obtained at the time of your appointment. Thank You!
Should be Empty:

New Patient Form

Responsible Party

Patient Information

Medical History

Patient Dental History

Cosmetic Questionnaire

Financial Policy