www.alamogordodentist.com

REGISTRATION
Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
Gender
If Child Parent Name
How do you wish to be addressed?
Phone: (best number to confirm)
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Employed By
Insurance Carrier SS#
Spouse Name
Spouse Employed By
Method of Payment
Insurance
Credit Card
Cash
Other members in this practice
Who may we thank for this referral
Emergency Contact
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance Coverage
Employee Name
Employee Date of Birth

MonthDayYear
Name of Insurance
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Member ID/ SSN
Release
I authorize the dentist and all staff to perform diagnostic procedures and treatment as may be necessary for proper dental care.

I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist.

I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me.

I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor.

I hereby agree to pay all costs of collection (including attorney fees), should any amount due hereunder be turned over for collection.

I attest to the accuracy of the information on this page.
Patient's or Guardian's Signature
Patient Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

REGISTRATION

Phone: (best number to confirm)

Emergency Contact

Dental Insurance Coverage

Release