Patient Registration


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:     Apt:     City:     State:     Zip:

Home Phone:     Work Phone: Ext:     Mobile:

Birth Date:    Social Security:    Drivers License:

Responsible Party is also a Dental Insurance Policy Holder for Patient


Patient Information:

Address:     Apt:     City:     State:     Zip:

Home Phone:     Work Phone: Ext:     Cellular:

Sex: Male Female     |     Marital Status: Married Single Divorced Separated Widowed

Birth Date:   Age:   Social Security:   Drivers License:

Email:   I would like to receive correspondence via email.

Section 2: Section 3:

Employer Name:

Employer Phone:

General Dentist:

Pref. Pharmacy/Phone:

Spouse Name/Phone:

Spouse Employer/Phone:

I was referred by:

Emergency Contact Name:

Emergency Contact Phone:

May we reach you by text? Yes No

Student Status: Full Time Part Time

Employment Status: Full Time Part Time Retired


Primary Dental Insurance Information:

Name of Insured:     Relationship to Insured: Self Spouse Child Other

Insured ID number:   Insured Birth Date:   Group Number:

Employer:

Address:

Address 2:

City, St, Zip:

Insurance Company:

Address:

Address 2:

City, St, Zip:

Rem. Benefits:   Rem. Deduct:


Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. 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 practitioners. I agree to be responsible for payment of all services rendered on my behalf or my dependents. In consideration of the services rendered or to be rendered, the undersigned agree(s) to pay for all services rendered in a manner acceptable with the office. In the event of default on payment, the undersigned agrees to pay all costs of collection, including attorney fees. The undersigned hereby waives all rights and claims of exemptions under state and federal laws.

Signature of Patient or Legal Guardian:  Enter Name:     Date: