Falcon Dental Group-Patient Registration Form

Patient Registration Form Patient Information

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'ii be glad to help you. We look forward to working with you in maintaining your dental health.

First Name*

Last Name*

Middle Name

Date Of Birth*

Address*

City*

State*

Zip*

Gender*

Marital Status*

Social Security Number*

Driving License Number

Home Phone

Cell Phone Number*

Email*

Business Address

Patient Employed By

Occupation

City

State

Zipcode

Business Phone

Business Email

Whom may we thank for referring you ?*

Patient Registration Form Patient Information

Emergency Contact*

Relationship to Patient*

Business Phone Number

Cell Phone Number*

Email

Home Phone Number

Patient Registration Form Primary Insurance

Person responsible for account

Last Name

First Name

Initial

Social Security Number

Relation To Patient

Date of Birth

Insured Person's Address

City

State

Zipcode

Home Phone

Cell Phone

Email

Patient Registration Form PRIMARY INSURANCE

Person Responsible Employed By

Occupation

Bussiness Address

City

State

Zipcode

Business Phone

Business Email

Insurance Company Name

Phone

Insurance Email

Contract #

Group #

Subscriber #

Name of other dependents under this plan

Patient Registration Form ADDITIONAL INSURANCE

Is patient covered by an additional insurance ?

Yes
No

Subscriber Name

Relation to Patient

Birth Date

Insured Address

City

State

Zipcode

Home Phone

Cell Phone

Email

Patient Registration Form ADDITIONAL INSURANCE

Subscriber Employed By

Business Phone

Business Email

Insurance Company

Insurance Phone

Business Email

Insurance Company

Phone

Insurance Email

Contract #

Group #

Subscriber #

Name of other dependents under this plan

Patient Registration Form FINANCIAL POLICY

Thank you for choosing us as your dental health care provider. We are committed to your treatment being successful. The following is a statement of our Financial Policy which requires you to read and sign prior to any treatment.

All patients must complete our lnfonnation and Insurance form before seeing the doctor.

FULL PAYMENT IS DUE AT TIME OF SERVICE.

WE ACCEPT CASH, CHECKS, VISA/MASTER CARD, AMERICAN EXPRESS and CREDIT CARDS.

REGARDING INSURANCE

Payment in full is required at the time of service. However, we may accept assignment of insurance benefits. If payment in full is not required, we will require your co-pay to be paid at the time of service. We cannot submit your insurance claim unless we have all insurance information and an original claim form. Failure to do so prohibits any submission and the entire balance will be immediately due and owing. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, the balance will be automatically transferred to your account. The balance is your responsibility whether your insurance company pays or not. Please be aware some of the services provided may be non-covered services by the Insurance Program and/or other medical insurance. 'I'his is not a statement by the insurance company that the service was unnecessary but rather a reason for rejection of payment by the insurance company. You are responsible for payment of all services rendered. All accounts due over sixty ( 60) days are subject to a 1.5% monthly finance charge.

USUAL AND CUSTOMARY RATES

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

MISSED APPOINTMENTS

Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at a 50% rate. Please help us serve you better by keeping scheduled appointments.

I have read the Financial Policy. I understand and agree to this Financial Policy.

SIGNATURE (Patient Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:18.234.247.75 )

Patient Registration Form Emergency Contact Information

Name

Phone Number

Patient Registration Form AUTHORIZATION

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriale and healthful dental treatment. If there ls any change in my medical status, I will lnform the dentist.

I authorize the insurance company Indicated on this form to pay to the denllst all insurance benefits otherwise payable to me for services rendered.I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment or benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment is due in full at time of treatment, unless prior arrangements have been approved.

SIGNATURE (Patient Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:18.234.247.75 )

Patient Registration Form Patient Information

Patient Registration Form Patient Information

Patient Registration Form Primary Insurance

Patient Registration Form PRIMARY INSURANCE

Patient Registration Form ADDITIONAL INSURANCE

Patient Registration Form ADDITIONAL INSURANCE

Patient Registration Form DENTAL HISTORY

Patient Registration Form Medical History

Patient Registration Form FINANCIAL POLICY

Patient Registration Form Emergency Contact Information

Patient Registration Form AUTHORIZATION

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