New Patient Registration Patient Details

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New Patient Registration Contact Information

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New Patient Registration Employment Information

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  •  the patient
  •  the person responsible for payment
  •  both
  •  not applicable

New Patient Registration Emergency Contact Information

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In an emergency who should be notified? Please enter Name and Phone number below:

New Patient Registration Responsible Party Information

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This only needs to be filled out if the insurance subscriber is other than patient, or you are the parent or guardian of the patient

  •  the patients spouse
  •  the person responsible for payment
  •  both
  •  neither-not applicable

New Patient Registration Primary Dental Insurance

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  •  By checking this box,

I authorize my insurance company to pay the dentist all insurance benefits rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.

  •  Yes
  •  No
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