Patient Registration Form Patient Details

1/6

Welcome to our Family and Cosmetic and Dental Office

Patient Registration Form Contact Information

1/6
  •  Email
  •  Home Phone
  •  Cell Phone
  •  Work Phone

Patient Registration Form Primary Insurance Details

1/6

Patient Registration Form Secondary Insurance Details

1/6

Patient Registration Form Assignment and Release

1/6

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Goochland Dentistry 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 hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

(Please click below to draw/upload sign)
(Your IP Address : IP:75.101.243.64 )

 CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

(Please click below to draw/upload sign)
(Your IP Address : IP:75.101.243.64 )

Preview