Patient Registration Thomas L. Dodson, DMD
First Name: Last Name: Middle Initial: Preferred Name:
Patient is: Policy Holder Responsible Party
Patient Information:
Address: Address 2:
City: State: Zip:
Home Phone: Work Phone: Ext: Mobile:
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.
Employment Status: Full Time Part Time Retired
Student Status: Full Time Part Time
Employer Id: Pref. Pharmacy:
Carrier Id: Pref. Hyg.:
I was referred by:
Emergency Contact Name:
Emergency Contact Phone:
Responsible Party (if someone other than the patient): First Name: Last Name: Middle Initial:
Birth Date: Social Security: Drivers License:
Responsible Party is also a Policy Holder for Patient
Dental Insurance Information:
Name of Insured: Relationship to Insured: Self Spouse Child Other
Insured Social Security: Insured Birth Date:
Employer:
Address:
Address 2:
City, St, Zip:
Insurance Company:
Group #: Rem. Benefits: Rem. Deduct:
ACKNOWLEDGEMENT OF RECEIPT of Notice of Privacy Practices:
I acknowledge that I have received a copy of Thomas L. Dodson, DMD Notice of Privacy Practices.
Patient Signature: Enter Name: Date: