Patient Registration

Date

Patient Registration

Patient Information

First Name

Middle Initial

Last Name

Patient Is:

Policy Holder Responsible Party

Preferred Name

Birth Date

Social Security #

Gender

Male Female Unspecified

Address

City

State

Zip Code

Email Address

Home Phone

Work Phone

Ext.

Cell Phone

What is the best way to reach you?

Home Phone Work Phone Cell Phone Email

Employment Status

Full Time Part Time Retired N/A

Student Status

Full Time Part Time N/A

Referred by

Responsible Party

Please complete this section if responsible party is someone other than the patient

First Name

MI

Last Name

Birth Date

Social Security #

Address

City

State

Zip Code

Home Phone

Work Phone

Ext.

Cell Phone

Primary Insurance Information

To avoid any misunderstanding regarding dental insurance, we want you to know that all professional services are charged directly to the patient and due when services are rendered. Please complete the information below to allow our office to assist you in preparing any necessary forms to help you obtain benefits from insurance companies.

Name of Insured

Relationship to Insured

Self Spouse Child Other

Other

Birth Date

Insurance ID #

Group #

Employer

Address

City

State

Zip Code

Insurance Company Name

Insurance Company Address

City

State

Zip Code

Emergency Contact Information

Emergency Contact

Cell Phone

Relationship to Patient