Patient Registration

Patient Name ___________________________________________________________

Preferred Name __________________________________                          

Mailing Address ________________________________________________________________

City, State and Zip ________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­______________________________________________________

Home Phone ___________________________________

Cell Phone ________________________________________

 E-Mail Address_________________________________________________________________

Sex:  M ___ F__   Age:  ______   Birth Date ____/_____/_____ Marital Status: Single ___ Married ___ Widowed___

Employed By _______________________________________________

Business Phone _____________________________________

Occupation ______________________________________

Social Security # ________________________________

PRIMARY DENTAL INSURANCE

Name of Policy Holder _______________________________________

Date of Birth ______/_______/________

 Employed by  _____________________________________________

BusinessPhone_________________________

Occupation ______________________________________________

Social Security #__________________________

Name of Dental Insurance Company ______________________________________

Phone#_____________________________________   

Address of Insurance Company______________________________________________________________________

Member ID # ___________________________________ Group # ________________________________

SECONDARY  DENTAL  INSURANCE

Name of Policy Holder _________________________________________

Date of Birth _______/________/________

Employed By ________________________________________________

Business Phone _____________________________

Occupation ______________________________________________

Social Security #_____________________________________

Name of Dental Insurance Company _______________________________________

Phone# ____________________________________

Address of Insurance Company ______________________________________________________________________

Member ID # _____________________________________ Group # _______________________

Emergency Contact ____________________________________________

Phone # ____________________________________________________

Relationship to Patient ____________________________________________________

Whom may we thank for referring you?_________________________________

PT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES CONSENT & RELEASE FORM