Patient Reg Form

PATIENT INFORMATION
Today's Date *

Month Day Year
Prefix

Mr. Mrs. Ms. Dr.
Sex:

Male Female
First Name *
MI *
Last Name *
Preferred Name
Birth Date *

Month Day Year
Age
Soc. Sec. #
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Whom may we thank for referring you to our office:

	Yes	No
Have you ever been a patient of our practice?
Has a family member ever been a patient of our practice?

Medical Doctor *

First Name Last Name
Preferred Pharmacy *
Tel. *

Area Code Phone Number
Driver's License #
Nearest relative not living with you

First Name Last Name
Tel.

Area Code Phone Number
Employer
Business Tel.

Area Code Phone Number
Personal Payment Type: *

Cash Check Credit Card
In case of emergency, please contact *
Tel. *

Area Code Phone Number
Relation *
Who Will Be Responsible For Your Account
*

Self (If self, skip this section) Spouse Father Mother Other
Name

First Name Last Name
Soc. Sec. #
Birth Date

Month Day Year
Age
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Driver's License #
Employer
Business Tel.

Area Code Phone Number
SPOUSE OR OTHER GUARANTOR INFORMATION (IF DIFFERENT FROM ABOVE)
Name

First Name Last Name
Relation
Soc. Sec. #
Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel:

Area Code Phone Number
Employer
Business Tel.

Area Code Phone Number
Insurance Information
Student

Full Time Part Time Not
School Name
School Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Marital Status:

Married Divorced Widow Single Legally Separated
Employed:

Full Time Part Time Retired Not Legally Separated
Do you belong to :

PPO HMO
Primary Dental Insurance Company
Employer
Business Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Tel.

Area Code Phone Number
Plan
Insurance Co. Name
ID #
Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel.

Area Code Phone Number
Group Name
Group #
Insured Party

First Name Last Name
Relation
Birth Date

Month Day Year
Sex:

M F
Soc. Sec. #
Tel.

Area Code Phone Number
Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Dental Insurance Company
Employer
Business Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Tel.

Area Code Phone Number
Plan
Insurance Co. Name
ID #
Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
Tel.

Area Code Phone Number
Group Name
Group #
Insured Party

First Name Last Name
Relation
Birth Date

Month Day Year
Sex:

M F
Soc. Sec. #
Tel.

Area Code Phone Number
Address

Address

Street Address Line 2

City State / Province

Postal / Zip Code
FEES & PAYMENTS
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.
Signature of patient (Parent or Guardian if Minor) *

Clear
Date *

Month Day Year
This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.
Signature of patient (Parent or Guardian if Minor) *

Clear
Date *

Month Day Year
AUTHORIZATION
I authorize my dentist and his / her designated staff, to perform an oral examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment
*

I permit the office to communicate with me via text message on my cell phone.
Signature of patient (Parent or Guardian if Minor) *

Clear
I have read the Dental Materials Fact Sheet provided at this link: https://www.dbc.ca.gov/formspubs/pub_dmfs_english_webview.pdf
Signature *

Clear
Date

Month Day Year
I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may has e regarding this Notice.

HIPAA-Notice-of-Privacy-Practices-highlighted-changes
Signature of patient (Parent or Guardian if Minor) *

Clear
Date *

Month Day Year
Please verify that you are human *
Should be Empty:

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PATIENT INFORMATION

Who Will Be Responsible For Your Account

SPOUSE OR OTHER GUARANTOR INFORMATION (IF DIFFERENT FROM ABOVE)

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

FEES & PAYMENTS

AUTHORIZATION