Patient Registration Form Patient Details

1/6

Patient Registration Form Contact Information

1/6
  •  Yes
  •  No

Patient Registration Form Emergency Contact Information

1/6

Other family members that are patients here : 

Patient Registration Form Primary Insurance Details

1/6

Insurance And Financial Information

  •  Yes
  •  No

Patient Registration Form Secondary Insurance Details

1/6
  •  I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balance due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he determines.

In consideration of the services rendered to me by the dental office I am obligated to pay said office in accordance with its credit terms and policy.

I consent to the making of videotapes, photographs, and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

(Please click below to draw/upload sign)
(Your IP Address : IP:34.205.93.2 )

Preview