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