1405 Old Alabama Road, Suite 100
Roswell, Georgia 30076
Phone: (770) 992-5779
Patient Registration
First Name:
MI:
Last Name:
Preferred Name
:
Patient is:
Policy Holder
Responsible Party
Address:
Line 1
Line 2
City:
State:
Zip Code:
Home Phone:
Work Phone:
Work Ext:
Mobile:
I would like to receive appointment reminders via text messages sent to my mobile phone.
Sex:
Male
Female
Marital Status:
Select
Single
Married
Separated
Divorced
Widowed
Birth Date:
Age:
Social Security:
Driver's License:
Email:
I would like to receive correspondences via e-mail.
Employment Status:
Full Time
Part Time
Retired
Student Status:
Full Time
Part Time
Employer ID:
Carrier ID:
Preferred Pharmacy:
Emergency Contact:
Emergency Phone:
Preferred Hygienist:
I was referred by:
Responsible Party
(if someone other than the patient)
First Name:
Last Name:
MI:
Address:
Line 1
Line 2
City:
State:
Zip Code:
Home Phone:
Work:
Mobile:
Birth Date:
Social:
Driver's Lic:
Responsible party is also a policy holder for patient.
Dental Insurance
Name of Insured:
Relationship to Insured:
Select
Self
Spouse
Child
Other
Insured Birth Date:
Insured Social:
Employer:
Employer Address:
City,St,Zip:
Insurance Co:
Insurance Co. Address:
City,St,Zip:
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.
*
Signature
of Patient, Parent or Guardian
:
Date
:
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