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Patient Registration
All fields in red are required!

First Name:
Last Name:
Middle Initial:
Preferred Name:
Patient is: Policy Holder
  Responsible Party
   
   

Responsible Party (if someone other than the patient)

   
First Name:
Last Name:
Middle Initial:
Address:
Address 2:
City:
State:
Zip:
   
Pager:
Home Phone:
Work Phone: ext.
Cellular:
   
Birth Date:
Social Security:
Drivers License:
Responsible Party
is also a: 		Policy Holder for Patient
  Primary Insurance Policy Holder

 Secondary Insurance Policy Holder
   
   

Patient Information

   
Address:
Address 2:
City:
State:
Zip:
Pager:
Home Phone:
Work Phone: ext.
Cellular
   
Sex:
Marital Status:
   
Birth Date:
Age:
Social Security:
Drivers License:
Email:
I would like to receive correspondence via email:
   
Employment Status:
Student Status:
Medicaid ID:
Preferred Dentist:
   
Employer ID:
Preferred Pharmacy:
Carrier ID:
Preferred Hygenist:
   
   

Primary Insurance Information

   
Name of Insured:
Relationship to Patient:
Insured Social Security:
Insured Birth Date:
   
Employer:
Employer Address:
Address 2:
City:
State:
Zip:
Rem. Benefits: $ .00
Rem. Deduct: $ .00
   
Insurance Company:
Address:
Address 2:
City:
State:
Zip:
   
   
Secondary Insurance Information
   
Name of Insured:
Relationship to Patient:
Insured Social Security:
Insured Birth Date:
   
Employer:
Employer Address:
Address 2:
City:
State:
Zip:
Rem. Benefits: $ .00
Rem. Deduct: $ .00
   
Insurance Company:
Address:
Address 2:
City:
State:
Zip:
   
   
 

Assignment and Release

I, the undersigned, have insurance with and assign directly to Dr. all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

Date Full Name

Minor/Child Consent

I, being the parent or guardian of do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to X-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when treatment is rendered.

Date Full Name of Insured/Guardian

Financial Agreement

I acknowledge that payment is due at the time of treatment. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full responsibility for all charges not covered by insurance.

Date Full Name of Insured/Guardian