Patient Registration

Date:
First Name: Last Name: MI:
I prefer to be called (nickname): E-mail address:
Address:
City: State/Zip:
Home Phone: Cell:
Work Phone: Preferred contact phone number:
Birth Date: Age: Sex: Male Female
Social Security#: Driver's license number:
Who may we thank for referring you?:
Why have you come to the dentist today?:
Occupation: Employer:
Student Status: Full Time Part Time Name of the School:
Person responsible for account: Name
Phone Number: Address:
Closest emergency contact not living with you: Name
Phone Number: Address:

Insurance Information

Primary Dental Insurance

Name of policy holder:
Relationship to patient: Self Spouse Child Other
Policy Holder's ID # Policy Holder's birth date
Group #
Employer Insurance Company
Address Address
City, State, Zip City, State, Zip

Secondary Dental Insurance

Name of policy holder:
Relationship to patient: Self Spouse Child Other
Policy Holder's ID # Policy Holder's birth date
Group #
Employer Insurance Company
Address Address
City, State, Zip City, State, Zip