Family Dentistry of St Peters-Patient Registration and Health History

Patient Registration and Health History Patient Details

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First Name*

Last Name*

Middle Name

Date Of Birth*

Address*

City*

Zipcode*

State*

Gender*

Marital Status*

SSN

Patient Prefers to be Addressed by the Following Name

Place of Employment

Occupation

If the Patient is a Child, Father's name

Mother's Name

Patient Registration and Health History Contact Info

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Telephone (Please fill preferred contact number)

Email*

Home Phone Number

Cell Phone Number

Work Phone Number

Work Extension Number

Preferred method of contact

Call
Text
Email

Patient Registration and Health History Emergency Contact Information

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In case of emergency, Whom should be notified?

Relationship

PLEASE SPECIFY

Phone Number

Patient Registration and Health History Responsible Party's Information

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*

Please check box if the information is same as above. (If so, you can disregard the following section)

Name

Birth Date

Social Security

Relationship to patient

Please specify

Address

City

State

Zip

Home Phone Number

Cell Phone Number

Work Phone Number

Relationship to Patient

Please specify

Place of Employment

Occupation

Email

Spouse's Name

Birth Date

Social Security

Place of Employment

Occupation

Cell Phone

Patient Registration and Health History INSURANCE DETAILS

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Insured's Name

Birth Date

Social Security

Address

City

State

Zip

Home Phone Number

Work Phone

Cell Phone

Insurance Company Address

City

State

Zip

Place of Employment

Occupation

Dental Insurance Company

Subscribers ID

Group #

Patient Registration and Health History Referral Information

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Our Practice Continues to Grow When Our Patients Refer Family and Friends.

Whom May We Thank for Referring You to our Office?

Patient Registration and Health History Authorization

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* The above information is accurate and complete to the best of my knowledge.

* I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

* I understand that I am financially responsible for all charges whether or not covered by insurance. As a courtesy this office will file insurance claims.

* I authorize this office to release information to secure the payment of benefits and I authorize insurance payments to be made directly to this office.

* All accounts will accrue late charges on balances exceeding ninety days.

* I am aware of and have been offered a copy of the privacy practices in place at this office, (HIPAA Law).

SIGNATURE (Signature of patient, parent, or guardian)*

(Please click below to draw/upload sign)

(Your IP Address : IP:3.239.40.250 )

Relationship to Patient

Please Specify

Patient Registration and Health History Patient Details

Patient Registration and Health History Contact Info

Patient Registration and Health History Emergency Contact Information

Patient Registration and Health History Responsible Party's Information

Patient Registration and Health History INSURANCE DETAILS

Patient Registration and Health History Referral Information

Patient Registration and Health History Medical and Dental History Form

Patient Registration and Health History Authorization

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