Patient Registration Form

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Download the Printable copy of this form.

  • Name:*

  • Address:

  • Phone:

    Cell/Pager:

  • Name of Doctor you are seeing:

    Email:

  • Patient Employed By:

    Phone and Ext:

  • Business Address:

  • Present Position:

  • Birthdate

    SS#

  • Marital Status MSWD

  • Name Of Spouse:

    Spouse Employed By:

  • Business Address:

  • Present Position:

  • In Case Of An Emergency, Whom should We Notify:

    Phone:

  • Do You Have Dental Insurances Yes/No:

    Group#:

  • Policy Holder:

    Policy#:

  • Relationship to Policy Holder:

    Policy Holder Birthdate:

  • Name Of Company:

    Phone:

  • Purpose Of Visit:

    Whom May We Thank for Referring You:

Consent Of Services Please Read Before Signing

Payment is expected in full at time of service. any Financial arrangements needing to be made must be made prior to scheduling a visit. Patients who carry dental insurance understand that all dental services firnished are charged directly to the patient and that he/she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms and submit them to your insurance company. However, this dental office cannot render services on the assumption that our charges will be paid by the insurance company. All emergency dental visits, or any dental services performed without previous financial arrangements, must be paid for in full at the time services are rendered

Our office follows all HIPAA guidelines to protect the privacy of your personal and healthcare information. By signing below you are acknowledging that we strive to follow these guidelines and that a copy of the privacy act is available to you if requested.

A broken appointment is a loss to everyone. We reserve the right to charge for appointments cancelled or broken without 24 hour notice.