PATIENT REGISTRATION INFORMATION

Todays Date *

Patient Name *

Birth Date *

Gender *

Marital Status *

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Mobile Phone *

Fax *

Email *

Patient SSN *

Patient Employer / School *

Occupation *

Person Responsible for Account *

Relationship to Patient *

How did you hear about us? *

Emergency Contact Name *

Relationship to Patient *

Emergency Contact Phone No. *

PRIMARY DENTAL INSURANCE INFORMATION

Birth Date *

Patient Relationship to Insurance Subscriber *

Self

Spouse

Child

OtherOther

Insured Last Name *

First Name *

Middle Initial *

Insured Address *

City *

State *

Zip Code *

Insurance ID# *

Insurance Group # *

Employer Name *

Insurance Company Name *

Insurance Company Phone # *

Insurance Address *

City *

State *

Zip Code *

SECONDARY DENTAL INSURANCE INFORMATION

Is this Patient covered by additional Dental Insurance? *

Yes

No

Birth Date *

Patient Relationship to Insurance Subscriber *

Self

Spouse

Child

OtherOther

Insured Last Name *

First Name *

Middle Initial *

Insured Address *

City *

State *

Zip Code *

Insurance ID# *

Insurance Group # *

Employer Name *

Insurance Company Name *

Insurance Company Phone # *

Insurance Address *

City *

State *

Zip Code *

I certify that I, and/or my dependents have insurance coverage as noted above, and assign directly to the dental office all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance information. The dental office may use my health care information and may disclose such information for the purpose of carrying out my treatment, payment, and healthcare operations.

STATEMENT OF PRIVACY POLICY We are committed to protecting medical information about you. The details of our Privacy Policy (The Notice) will tell you about the ways in which we may use and disclose information about you. The Notice also describes your rights and outlines obligations we have regarding the use and disclosure of your information. We are required by law to make sure the medical information we have that identifies you is kept private. We Are required by law to give you a copy of our Notice of legal duties and privacy practices and to follow the terms of the Notice that is currently in effect. The Notice of our Privacy Policy can be obtained when you visit our office.

Patient or Legal Guardian Name *

Relationship to Patient *

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PATIENT REGISTRATION INFORMATION