Patient Registration

Patient Information

Last Name:   First Name:   Middle Initial:

Age:   Birth Date:     Sex:   Male     Female

Social Security Number:     Drivers License Number:

Employer:

Home Address:

City:     State:     Zip:

Home Phone Number:     Work:     Cell:

Email Address:

Would you like to sign up for email/text reminders about upcoming appointments, specials or promotions?

Yes   No       If yes, please indicate the best method of contact: Email   Text

Dental Insurance Policy Holder Information

If you do not have dental insurance please initial here:

Last Name:   First Name:

Birth Date:     Social Security Number:

Home Address:

City:     State:     Zip:

Employer Name:     Employer Phone:

Employer Address:

City:     State:     Zip:

Insurance Company Name:     Insurance Co. Phone:

Insurance Co. Address:

City:     State:     Zip:

Group Name:     Group Number:

Member/Provider ID:

Responsible Party Information

Is the responsible party the same as the patient information above? Yes   No

If you answered no, please fill out the information below.

Last Name:   First Name:

Birth Date:     Social Security Number:

Home Address:

City:     State:     Zip:

Home Phone Number:     Work:     Cell:

I certify the above information is accurate to the best of my knowledge. I understand if any of my information changes, it is my responsibility to notify Premier Family Dentistry immediately.

Patient Signature:     Date:

Parent/Guardian signature if patient is a minor.