PATIENT REGISTRATION FORM

1. ABOUT YOU

2. SPOUSE INFORMATION

3. DENTAL INSURANCE

Primary Dental Insurance

Secondary Dental Insurance

4. FINANCIAL RESPONSIBILITY

I acknowledge that I am responsible for all charges for services provided, including any amount not paid by my insurance plan. If collection procedures become necessary I agree to pay all attorney and collection fees.

I acknowledge I have received a copy of this office’s Notice of Privacy Practices.

I also authorize the release of all dental information necessary for processing insurance claims to my insurers or any third party or their agents.

I understand that 48 business hours notice for cancellations is required or I may be subject to a $75 service fee.

5. MEDICAL / DENTAL HISTORY

 

Do you have or have you ever had:

Are you allergic to:

Do you have or have you ever had:

7. APPEARANCE SATISFACTION