Registration Form

 

Patients Name *
Patients Name
If Child: Parent's Name
If Child: Parent's Name
How do you wish to be addressed? *
How do you wish to be addressed?
*
Residence
Residence
Business Address
Business Address
Home Phone Number *
Home Phone Number
Work Phone Number *
Work Phone Number
Cell Phone Number *
Cell Phone Number
Who is responsible for this account? *
Who is responsible for this account?
Method of Payment *
Dental Insurance: 1st Coverage
Dental Insurance: 1st Coverage
Employee Name
Address
Address
Telephone
Telephone
Dental Insurance: 2nd Coverage
Dental Insurance: 2nd Coverage
Employee Name
Address
Address
Telephone
Telephone
Consent *
Consent
I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment. I consent to the disclosure of my records (or my child's records) to the following persons who are involved in my care (or my child's care) or payment for that care.
*
My consent to disclosure of records shall be effective until I revoke it in writing. I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, by my dental care payor. I attest to the accuracy of the information on this page.
Date *
Date