Adult Registration- Madison Dentistry

Adult Registration Form
Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental heathcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help.
Personal Information
Date

MonthDayYear
Birthdate

MonthDayYear
SS #/SIN
E Mail
example@example.com
Name
Wishes to be called
Gender

MaleFemaleMinorSingleMarriedDivorcedWidowedSeparated
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Referred by
Responsible Party

Who is responsible for the account?
Name
Relationship to patient
Birthdate

MonthDayYear
Driver's License #
SS #/SIN
Address
Email
example@example.com
City
State/ Prov
Zip/PC
Employer
Occupation
Work Phone
Ext. #
Home Phone
Cell Phone
Please enter a valid phone number.
Telephone
Home Phone
Work Phone
Ext. #
Cell Phone
Where do you prefer to receive calls?

HomeWorkPhone
When is the best time to reach you?
Time
Days
In the event of an emergency, who should we contact?
Name
Relationship
Work #
Home #
Dental Insurance Information

Primary Insurance
Name of Insured
Relationship to patient
Insured's birthdate

MonthDayYear
SS #/SIN
Employer
Date Employed

MonthDayYear
Date
Occupation
Insurance Company
Group #
Employee/Cert #
Ins. Co. Address
Deductible
Amount already used
Max. annual benefit
Additional Insurance
Name of Insured
Relationship to patient
Insured's birthdate

MonthDayYear
Date
SS #/SIN
Employer
Date Employed

MonthDayYear
Occupation
Insurance Company
Group #
Employee/Cert. #
Ins. Co. Address
Deductible
Amount already used
Max. annual benefit
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. Iunderstand 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.
Signature of patient or parent/guardian if minor

Clear
Date

MonthDayYear
Financial Arrangements
For your convenience, we offer the following methods of payment Please check the option which you prefer. Payment in full at each appointment.
Cash
Personal Check
Credit Card
Visa
MC
I wish to discuss the dental office's policy.
Late Charges
If do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

Thank you for filling out this form completely. The information you have provided will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask we are always happy to help.
Should be Empty:

Adult Registration Form

Personal Information

Responsible Party

Telephone

Dental Insurance Information

Financial Arrangements

Late Charges