Patient Registration Form

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Personal Details
Add Address Details
Add Emergency Details
Do you have Insurance?      

*

Disclaimer

I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.


Patient or Guardian Signature *

Heart Conditions
Blood Disorder
Intestinal Conditions
Bone or Joint Conditions
Bone Density Conditions
Feminine Conditions
Substance Abuse
Birth/Development Conditions
Other Conditions
Allergy Conditions
Are you taking any medications?
Dental Form
Do you have any of the following ?
Previous dental history?

Disclaimer

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.


Patient or Guardian Signature *