Patient Registration
Patient is:
Patient Information
Sex:
Martial Status:
Employment Status:
Student Status (if over 18):
(Proof may be required by your insurance company before a claim can be paid)
Emergency Contact
Responsible Party (If someone other than the patient)
Responsible Party has patient covered under their insurance:
Primary Insurance Information
Relationship to Patient:
Are you allowed to receive phone calls at work to confirm an appointment:
Secondary Insurance Information
Relationship to Patient:
Are you allowed to receive phone calls at work to confirm an appointment:
Medical History
Are you under a physicians care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take or have you taken Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Are you under a physicians care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take or have you taken Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Woman - Are you:
Are you allergic to any of the following?
Do you have or have you had any of the following?
Have you ever had any serious illness not listed above?

I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless other arrangement have been made. In the event payments are not received by the agreed upon dates, I understand that a 1-1/2% charge (18% APR) may be added to my account.

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. 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.

A broken appointment fee may be added to my account without a 48 hour cancellation hour.