PATIENT REGISTRATION FORM

Today's Date:

PATIENT REGISTRATION

Last Name
First Name
M.I.
Nickname
Birthdate
Age
Sex F
Address 
City
State
Zip
Student Status FT  PT
School
Location
Home Phone
Cell Phone
Work Phone
Employer
Business Address
E-mail
Yrs. Employed
Soc. Sec. No.
Marital Status  S M D W
Spouse's Name
Spouse's Employer
Emergency Contact Name
Relationship
Phone

PERSON RESPONSIBLE FOR THIS ACCOUNT

Responsible Party's Name
Relationship to Patient
Street Address
Phone
Employer
Years Employed
Soc. Sec. No.
Business Address
Phone

FOR PATIENTS WITH DENTAL INSURANCE

Subscriber's name
Birthdate
Soc. Sec. No.
Employer
Insurance Company
Insurance Company Phone #:
Group No.
Insurance Company Mailing Address
Patient's Relation to Subscriber: Self Spouse Dependent
Have you Used Your Dental Insurance This Benefit Year?  Yes No

HOW DID YOU HEAR ABOUT OUR OFFICE

Where did you find the phone number to this office? (please check below) 
Referred by a friend
Housewarmers
Sign on Building
Yellow Pages
Lakeside Living Magazine
Other Dr
Relative
Direct Mailing
Suburban Parent Magazine

If you were referred, whom may we thank for referring you?


CONSENT FOR TREATMENT/RESPONSIBILITY OF PAYMENT

  1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis and treatment plan.
  2. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
  3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks.
  4. 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 provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information has been given to me.
  5. 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.
  6. I agree to give at least 48 hours notice of a change in appointment whenever possible. I understand that missed and/or cancelled appointments without adequate notice may be subject to a fee at the following rates: Hygiene appointment $75 Doctor Appointment: $150
  
Patient's Signature
or for patient under the age of 18
Parent/Responsible Party's Signature
Date:
Relationship to Patient (enter "self" for self):