Patient Registration Form printable pdf download

CONFIDENTIAL

Patient Registration Information

Date:______________________

Name:_______________________________________________

Birthdate: _____________________

(First)

(Mi)

(Last)

Welcome to our practice! Please fill out this form completely in ink. If you have any questions or concerns, please do not

hesitate to ask for assistance. We are happy to help!

Address:__________________________________ City:________________ State:______ Zip:__________

Home Phone:___________________ Work Phone:_________________ Cell Phone:___________________

Email:_______________________ SS# _____________________ Drivers License #: __________________

Are you?

□ Minor

□ Single

□ Married

□ Divorced

□ Widowed

□ Separated

Your/ Parent or Guardian’s employer: ____________________________Occupation:________________

Business Address: ___________________________City: _______________ State:_______ Zip:_________

Emergency Contact: ______________________________________ Phone:________________________

Responsible Party:

□ Same as above

Name of person for this account: _______________________________ Relationship:________________

Address:___________________________ _______ City:________________ State:______ Zip:__________

Home Phone:___________________ Work Phone:_________________ Cell Phone:___________________

Birthdate:________________ SS# _______________________ Drivers License #: ____________________

Employer:_____________________________________________ Occupation:_______________________

Is this person currently a patient in our office?

□ Yes

□ No

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination

rendered to me during the period of such Dental care to third party payors and/ or other health practitioners.

I authorize and hereby request my insurance company to pay directly to the dentist insurance benefits otherwise payable

to me.

I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for

payment of all services rendered on my behalf or on the behalf of my dependents.

X________________________________________________

_____________________

Signature of patient or parent/ guardian if minor

Date

Late Charges: If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1% on the

balance then unpaid and owed will be assessed each month. I realize that failure to keep this account current may result

in your being unable to provide additional dental services except for dental emergencies or where there is prepayment for

additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable

attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

Patient Registration Form

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