www.smileoasis.com - New Patient Registration Form

New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Thank you for selecting our dental healthcare team!
We will strive to provide you with the best possible dental care.
Patient Information (Confidential)
Patient Name*

First NameMiddle NameLast Name
Your Date of Birth

MonthDayYear
Social Security Number
Marital Status
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code / Apt Number
Place of Employment
Email Address*
example@example.com
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
If Patient is Minor
Parent’s Name
Parent's Employer
Work Phone Number
Please enter a valid phone number.
Spouse’s Details
His/Her Name
Employer
How did you hear about us?
Person to Contact in Case of Emergency
His/Her Name*
Phone Number*
Please enter a valid phone number.
Responsible Party (Responsible for this account)
His/Her Name
Relationship
Date of Birth

MonthDayYear
Driver’s License Number
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Is this person a patient in our office?

YesNo
For your convenience, we offer the following methods of payment. Please check one. Payment is made in full at each appointment.

CashCheck
Credit Cards

VisaMasterCardDiscoverCareCredit (upon qualifying)
Dental Insurance Information
Name of Insured
Ins.Co.Phone #
Please enter a valid phone number.
Insurance Co Name
Date of Birth Insured

MonthDayYear
Relationship
SS# of Insured
Name of Employer
Work Phone Number
Please enter a valid phone number.
Authorization & Release Information
Please check this*

I certify that I have read and understood the above information to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information on my medical history can be dangerous to my health. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third-party payers and /or health care practitioners. I authorize and request my insurance company to pay directly to the dentist benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual dental bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Please check this*

I consent to the making of photos and x-rays before, during, and after treatment and the use of them by the dentist in scientific papers or demonstrations.
Please check this*

I certify that I have read, or have been read to me, the contents of this form and do realize the risks and limitations involved.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration Form

Patient Information (Confidential)

If Patient is Minor

Spouse’s Details

Person to Contact in Case of Emergency

Responsible Party (Responsible for this account)

Dental Insurance Information

Authorization & Release Information