Patient Registration
Date
Last Name
First
M.I.
Prefers to be called by
City
State
Zip
Home Phone No.
Cell
E-mail
Birthdate
Age
Sex
Male
Female
Relationship
Married
Single
Divorced
Widowed
Social Security No.
Account Information
Person Financially Responsible For Account
Name
Relationship To Patient
Social Security No.
Address
City
State
Zip
Phone No.
Dental Insurance
Primary Carrier
Insurance Company
Group No.
Employer’s Name
Insured’s Name
Date of Birth
Relationship to Patient
Insured’s I.D. No.
Insured’s Social Security No.
Secondary Carrier
Insurance Company
Group No.
Employer’s Name
Insured’s Name
Date of Birth
Relationship to Patient
Insured’s I.D. No
Insured’s Social Security No.
Getting to know you
Is Another Member Of Your Family Or Relative A Patient at Our Office?
Name:
Relationship:
You were referred to us by
Name
Person to Contact For Emergency
Name:
Cell Number
Home Number:
City
State
Zip
Consent for Treatment
I here by authorize doctor or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (Type Patient's Name here) Type Name Of Patient Here dental needs.
Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to proved quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
Patient’s Signature
Date
Parent/ Responsible Party’s Signature
Relationship to patient
Submit