clearcareperio.com - New Patient Registration Form [7 - 01

Patient Registration Form
Today’s Date:*

MonthDayYear
Date
Preferred Pronoun
Patient's Name:*

First NameLast Name
Preferred Name
Date of Birth *

MonthDayYear
Address:*

Address

Street Address Line 2

CityProvince / State

Postal Code / Zip Code
Cell phone # :*
Please enter a valid phone number.
Email address:*
example@example.com
Preferred Contact

EmailCell PhoneText Messaging
Family Physician*
Address:

Address

Street Address Line 2

CityProvince / State

Postal Code / Zip Code
Phone Number
Please enter a valid phone number.
Preferred Pharmacy
Address:

Address

Street Address Line 2

CityProvince / State

Postal Code / Zip Code
Phone Number
Please enter a valid phone number.
Insurance Information

(Please give your insurance card to the receptionist)
Primary Dental Insurance Provider:
Primary Dental Insurance Provider
Name of Insured:
Address (if different):

Address

Street Address Line 2

CityProvince / State

Postal Code / Zip Code
Date of Birth

MonthDayYear
Group/Policy #
Certificate/ID
Do you have Secondary Dental Insurance?*

YesNo
Secondary Dental Insurance Provider
Name of Insured:
Date of Birth

MonthDayYear
Address (if different):

Address

Street Address Line 2

CityProvince / State

Postal Code / Zip Code
Group/Policy#
Certificate/ID
Patient’s relationship to subscriber
In Case of Emergency
Name:*
Relationship:*
Cell Phone #:
Please enter a valid phone number.
I authorize the specialist to conduct a dental examination and perform treatment as deemed necessary for proper dental care.

I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.

I understand that I am responsible for payments in full for all professional services at the time each service is performed. I understand that an estimate of treatment costs will be given to all new and recall patients and that actual cost for services may be higher or lower. By signing this form, I revoke all previous agreements to the contrary and agree to be responsible for payment of service not paid in whole or in part by my dental care provider.

I authorize the communication and release of information concerning my (my child’s) related treatment to other dentists or specialists.

I authorize the communication and release of information contained in my claim forms to my insurance provider/plan administrator.

APPOINTMENT POLICY: Our policy requires that if you wish to cancel an appointment, you must provide our office with 2 business days notice. Please note that we are unable to accept cancellations via email or after hours. Appointment cancellations with less than 2 business days notice may incur a $100 fee.

I have read the above conditions and agree with their content.
Signature of Patient/Guardian*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Patient Registration Form

Insurance Information

Primary Dental Insurance Provider:

In Case of Emergency

Dental History

IMAGE RELEASE CONSENT

Medical History