Dental

Dental Registration and History

1. PATIENT INFORMATION

patient name Last Name First Name Middle Initial

date birthday

SS# or Insurance ID# sex M F

address

city state zip

home tel work tel

mobile occupation

email marital status

Referral Source

notes

2. EMPLOYER / SCHOOL

Employer/ School Name

Address

city state city

phone email

notes

3. EMERGENCY CONTACT

Emergency Contact Name

Address

city state city

phone relationship

4. INSURANCE INFORMATION

Responsible Party Name

Relationship to Patient

Insurance Company

Subscriber Name

Group # SS #

Birthday Other Coverage yes no

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with:

and assigned directly to Dr. all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named dentist may use my health care information and may disclose such information in the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan to completed or one year from the date signed below.

Signature Date

5. DENTAL HISTORY

Reason for today's visit

former dentist tel Last X-Ray Date

last cleaning last dental visit

do you feel pain Yes No if yes please describe

Do you feel numbness, swelling, or any other sensitivity? Yes No if yes please explain

Additional comments about your past dental history