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Patient Registration Form

Dr. Andrew Spath

2121 East Coast Hwy Ste 290,
Newport Beach, CA 92625
(949) 612-2356

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
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  •  No
Emergency Contact Information( * mandatory to fill )

Other family members that are patients here : 

Primary Insurance Details( * mandatory to fill )

Insurance And Financial Information

  •  Yes
  •  No
Secondary Insurance Details( * mandatory to fill )
  •  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.

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