drmargaretkirkland.com - Registration

  • Patient information

  • Gender
  • Birthdate
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • RESPONSIBLE PARTY

  • I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services I may need during diagnosis and treatment with my informed consent.

    I understand that it is my responsibility to inform Dr. Kirkland’s office within twenty-four business hours of any cancelation for my appointment and that there will be a broken appointment fee assessed in the absence of said notice.

    Our responsibility is only to you, the patient. Payment is due at the time of service. In the event it becomes necessary to collect a delinquency to your account through legal process or by utilization of an attorney or collection agency, by signing this form you are expressing your agreement to pay unto Margaret Kirkland DDS any and all costs incurred by her in effecting this collection, including all legal, attorney and collection fees. The undersigned warrants and represents their lawful capacity to enter into this agreement, and their personal liability and obligation as herein expressed.

  • Date
     - -

  • Dental Insurance

  • Dr. Kirkland does not accept assignment of insurance and I understand it is my responsibility to know the type of coverage, what and how much my plan will pay. Dr. Kirkland will file my insurance as a courtesy, but I understand all fees are due at the time of service.

  • Insurance Information(if applicable):

  • Student:
  • Marital Status:
  • Employed:

  • Primary Dental Insurance Company:

  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Is patient covered by additional insurance plan?
  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • Format: (000) 000-0000.

  • Dental History

  • Format: (000) 000-0000.
  • Date of last dental visit
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  • Date of last dental x-rays
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  • Dental Issues

  • Health History

  • Format: (000) 000-0000.
  • Date of last visit
     - -
  • Have there been any changes in your health in the past year?
  • Have you had any illness, surgery or been hospitalized in the past five years?
  • Rows

  • Women:

  • Pregnant
  • Due Date
     - -
  • Nursing

  • Allergies

    (Please consider options carefully and check all that apply)
  • Rows

  • Medications

  • Notice of Privacy Practices (HIPAA)

  • By signing this document, and only as permitted by state or federal law, you are giving this practice your consent to do the following:

    To disclose or request your health information, including diagnosis, treatment information, and x-rays to other healthcare professionals, providers, and insurance companies.

    To leave appointment reminders on answering devices or with designated appointees

  • Date
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  • Should be Empty: