Patient Registration Form

Patient Name:

If a child
Name of Guardian:

Relationship:

Residence Mailing Address:

City:

State:

ZIP:

Telephone: Home

Telephone: Cell

Telephone: Work

Email Address:

Patient/Parent Employer

Person responsible for account

Patient Social security#

Other family members in this practice:

Someone to notify in case of Emergency- Name and Phone Number:

How did you hear about us?

I authorize payment of insurance benefits directly to the dentist of dental group otherwise payable to me.
I understand that my dental care insurance carrier or payer of my dental benefits may pay less that the actual bill of services. I understand I am financially responsible for payment in full of all accounts.

Date:

Patient or Guardian Signature:

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