bellahanonofamilydentistry.com - Patient Registration

Name*

First NameMiddle NameLast Name

SS#

Preferred Name

Date of Birth*

Date

Gender*

Marital Status

Address*

Street City State Zip

Email*

example@example.com

Home Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Work Phone

Area CodePhone Number

Employer

Occupation

May we call you at your work number?

Who may we thank for referring you to our office?

Name*

First NameLast Name

SS#

Address*

Street City State Zip

Phone *

Area CodePhone Number

Email*

example@example.com

Date of Birth

Date

Employer

Occupation

Insured’s Name

First NameLast Name

Insured’s Employer

Date of Birth

Date

Dental Insurance Company

Address

Street City State Zip

Group

Policy #

ID #

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

I certify that I have completed this form fully and completely. The above information is accurate to the best of my knowledge and I understand that providing false information can be dangerous to my health. I grant authority to the Dentist and staff to perform the necessary exam, x-rays, and subsequent treatment needed to restore and maintain my dental health or the health of my dependent.

I authorize and request my insurance company to pay benefits on my behalf directly to the dentist. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents, including any collection costs.

Signature*

Name*

First NameLast Name

Date*

Date

Patient Registration

Spouse/Responsible Party information

In an emergency, who should be notified?