Dental Registration And History

1. Patient Information

Date

SS/HIC/Patient ID #

Patient Name

Address

E-mail

City

State

Zip

Sex

M F

Age

Birthdate

Married

Widowed

Single

Minor

Separated

Divorced

Partnered for

Years

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Birthdate

SS#

Spouse's Employer

Whom may we thank for referring you?

2. Dental Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes No

Subscriber's Name

Birthdate

SS#

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance Company(ies)

and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care intormation and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable“ for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient

3. Phone Numbers

Home

Work

Ext

Cell Phone

Spouse's Work

Best time and place to reach you

In case of Emergency, Contact (Specify someone who doesnot live in your household.)

Name

Relationship

Home Phone

Work Phone

6. Updates(To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?

Yes No

For what conditions?

Are you taking any new medications?

If so, what?

Patient's Signature

Date

Doctor's Signature

Date

Has there been any change in your health since your last dental appointment?

Yes No

For what conditions?

Are you taking any new medications?

If so, what?

Patient's Signature

Date

Doctor's Signature

Date