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PATIENT REGISTRATION

First Name:

Last Name:

Middle Initial:

Preferred Name:

Patient Is:

Policy Holder

Responsible Party

Responsible Party (if someone other than the patient)

First Name:

Last Name:

Middle Initial:

Address:

Address 2:

City, State, Zip:

Home Phone:

Work Phone:

Ext:

Cellular:

Pager:

Birth Date:

Age:

Social Security:

Drivers License #:

Policy Holder Type:

Responsible Party is also a Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Insurance Policy Holder

Patient Information

Address:

Address 2:

City:

State / Zip:

Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Sex:

Male

Female

Marital Status:

Married

Single

Divorced

Separated

Widowed

Birth Date:

Age:

Social Security #:

Drivers License #:

E-mail:

I would like to receive correspondences via e-mail.

Employment Status:

Full Time

Part Time

Retired

Student Status:

Full Time

Part Time

Medicaid ID:

Preferred Dentist:

Employer ID:

Preferred Pharmacy:

Carrier ID:

Preferred Hygienist:

Additional Comments:

Primary Insurance Information

Name of Insured:

Relationship to Insured:

Self

Spouse

Child

Other

Insured Social Security #

Insured Birth Date:

Employer:

Address:

Address 2:

City, State, Zip:

Insurance Company:

Address:

Address 2:

City, State, Zip:

Secondary Insurance Information

Name of Insured:

Relationship to Insured:

Self

Spouse

Child

Other

Insured Social Security #

Insured Birth Date:

Employer:

Address:

Address 2:

City, State, Zip:

Insurance Company:

Address:

Address 2:

City, State, Zip:

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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