Patient Registration
Leanne L. Mcdonald, DMD, FAGD


Patient Information

Who may we thank for referring you? Another Patient   Their Name:

    Dental Office   Yellow Pages   Newspaper   School   Work   Other

Preferred Pharmacy:   Pharmacy Phone:

First Name:   Middle Initial:   Last Name:     Preferred Name:

Address:     Apt:     City:     State:     Zip:

Gender: Male Female     |     Family Status: Married Single Divorced Separated Widowed

Home Phone:     Cellular:

Birth Date:   Social Security:   Email:  

Work Phone: Ext:     Occupation:

Employer Name:   Employer Address:

Next of Kin:   Contact#

Responsible Party (if not same as patient):

Responsible Party:   Patient   Other

First Name:   Middle Initial:   Last Name:     Preferred Name:

Gender: Male Female     |     Family Status: Married Single Divorced Separated Widowed

Address:     Apt:     City:     State:     Zip:

Home Phone:     Work Phone: Ext:     Cellular:

Birth Date: Social Security: Drivers License:

Employer Name:   Employer Address:


Insurance Information

Insured is the: Patient   Responsible Party Other

Name of Insured:   First Name:   Middle Initial:   Last Name:

Gender: Male Female     Birth Date:   Social Security:

Home Address:   Home Phone:

Employer Name:   Employer Phone:

Insurance Company Name:   Phone:

Contract Number:   Group Number:


Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time the services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare patient insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1 1/2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or her assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home, via cell phone, or at my work to discuss matters related to this form. I have read the above conditions of treatment and agree to their content.

Signature of Patient, Parent, or Guardian:   Enter Name:   Date:
Relationship to Patient: