NEW PATIENT REGISTRATION FORM Name * First Name Last Name PREFERRED NAME * GENDER * FEMALE MALE FAMILY STATUS * SINGLE MARRIED CHILDREN OTHER BIRTH DATE * MM DD YYYY SOCIAL SECURITY NUMBER * PREVIOUS VISIT MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * PHONE NUMBER * BEST TIME TO CALL * WOULD YOU LIKE TO RECEIVE A TEXT REMINDER? * YES NO WOULD YOU LIKE TO RECEIVE AN EMAIL REMINDER? * YES NO PREFERRED APPOINTMENT TIMES * MONDAY MORNING MONDAY AFTERNOON MONDAY EVENING TUESDAY MORNING TUESDAY AFTERNOON TUESDAY EVENING WEDNESDAY MORNING WEDNESDAY AFTERNOON WEDNESDAY EVENING THURSDAY MORNING THURSDAY AFTRENOON THURSDAY EVENING FRIDAY MORNING FRIDAY AFTERNOON FRIDAY EVENING NO PREFERRENCE NAME OF PERSON, OFFICE, OR OTHER SOURCE REFERRING YOU TO OUR PRACTICE? * SPECIAL INTERESTS OR HOBBIES EMERGENCY CONTACT NAME * EMERGENCY CONTACT PHONE NUMBER * PRIMARY DENTAL INSURANCE INFO * First Name Last Name BIRTH DATE * MM DD YYYY ID # * GROUP # * INSURED'S ADDRESS * Address 1 Address 2 City State/Province Zip/Postal Code Country INSURED'S EMPLOYER NAME * EMPLOYER ADDRESS * Address 1 Address 2 City State/Province Zip/Postal Code Country PATIENT'S RELATIONSHIP TO INSURED * SELF SPOUSE CHILD OTHER INSURANCE PLAN NAME * INSURANCE ADDRESS * Address 1 Address 2 City State/Province Zip/Postal Code Country SECONDARY DENTAL INSURANCE INFO First Name Last Name BIRTH DATE MM DD YYYY ID # GROUP # INSURED'S ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country INSURED'S EMPLOYER NAME ENSURED'S EMPLOYER ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country PATIENT'S RELATIONSHIP TO INSURED SELF SPOUSE CHILD OTHER INSURANCE ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country CONSENT FOR SERVICES * I HAVE RECEIVED A COPY OF S+S PRIVACY PRACTICES + DENTAL MATERIALS FACT SHEET. I HAVE READ THE ABOVE CONDITIONS OF TREATMENT + PAYMENT + AGREE TO THEIR CONTENT. I HAVE RECEIVED A COPY OF INFORMED CONSENT FOR DENTAL TREATMENT. I GRANT PERMISSION TO YOU OR YOUR ASSIGNEE TO TELEPHONE ME TO DISCUSS THIS STATEMENT OR MY TREATMENT. As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within seven (7) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. SIGNATURE OF PATIENT, PARENT OR GUARDIAN {RESPONSIBLE PARTY} * RELATIONSHIP TO PATIENT * Thank you!
