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Patient Registration Form

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Additional Insurance( * mandatory to fill )
Assignment and Release( * mandatory to fill )

for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. 

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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