Patient Registration

Patient Registration
Patient Information
Legal Name:*

First NameLast Name
Preferred Name:
Birthdate:*

MonthDayYear
Date
Sex:*

MaleFemaleOther
Is the patient under the age of 18?*

YesNo
Social Security Number:*
Social Security Number:*
Name of Parent/Guardian:*

First NameLast Name
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address different than your physical address?*

YesNo
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Cell Phone Number:
Email:*
example@example.com
How did you hear about us?*

Internet SearchFacebookWord of mouthReferred by current patientReferred by medical professionalOther
Name of patient who referred you:
Name of medical professional that referred you:
Emergency Contact
Name:*

First NameLast Name
Phone Number:*
Relationship to Patient:*
Responsible Party
Is someone other than the patient financially responsible for this account?*

YesNo
Name of Responsible Party:*

First NameLast Name
Relationship to Patient: *
Phone Number:*
Social Security Number:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance
Do you have dental insurance?*

YesNo
Primary Coverage
Name of Policyholder:*

First NameLast Name
Policyholder's Birthdate:*

MonthDayYear
Date
Patient's Relationship to Policyholder:*
Name of Plan Sponsor (employer, union, health insurance carrier):*
Name of Insurance Company:*
Insurance Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number:
Member ID or Policyholder SS#:*
Group #:
Upload Picture of Insurance Card:

Browse Files

Cancelof
Do you have any additional dental coverage?*

YesNo
Secondary Coverage
Name of Policyholder:*

First NameLast Name
Policyholder's Birthdate:*

MonthDayYear
Date
Patient's Relationship to Policyholder:*
Name of Employer:
Name of Insurance Company:*
Insurance Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number:
Member ID or Policyholder SS#:*
Group #:
Upload Picture of Insurance Card:

Browse Files

Cancelof
I authorize Dr. Speer and his staff to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis. I also authorize Dr. Speer to perform any and all forms of treatment, medication, and therapy that may be indicated. I also understand that the use of anesthetic agent, medications, and some dental procedures embody a certain risk. I authorize my insurance company to pay Oak Grove Dental Center all the insurance benefits for services rendered. I also authorize the release of all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not they are covered by my insurance. I also acknowledge that my payment is due at the time of treatment.
Signature of Patient or Guardian:*

Clear
Should be Empty:

Patient Registration

Patient Information

Emergency Contact

Responsible Party

Dental Insurance

Primary Coverage

Secondary Coverage