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444 Forest Square, Suite G, Longview, Texas 75605 | Directions

New Patient Registration Form

Print blank form to fill by hand

Please note that it is important to fill in all the fields before submitting. Thank you.

Thank you for selecting our dental healthcare team!
We will strive to provide you with the best possible dental care.
PATIENT INFORMATION (CONFIDENTIAL)
Patient Name :
*Last Name :
Middle Name : *First Name :
*Your birthday :
Social security# :
Marital Status : Single Married Divorced Widowed Minor Separated
*Home Address
City :
State :
Zip :
Apt# :
Place of Employment:
*Email address :
*Home Phone#: ()--
Work Phone#: ()---
Cell Phone# : ()--
If Patient is Minor -
Parent’s Name:
Parent's Employer: Work Phone# : ()---
Spouse’s Details -
His/Her Name : Employer:
How did you hear about us?
Person to Contact in Case of Emergency -
His/Her Name : Phone# : ()- -
RESPONSIBLE PARTY (RESPONSIBLE FOR THIS ACCOUNT)
His/Her Name : Relationship :
Birthday :
Driver’s License # :
Address : City :
State : Zip :
Phone#: ()--
Cell Phone#: ()--
Is this person a patient in our office? Yes No
For your convenience, we offer the following methods of payment. Please check one. Payment made in full at each appointment.
Cash Check      Credit Cards: Visa MasterCard Discover CareCredit (upon qualifying)
DENTAL INSURANCE INFORMATION
Name of Insured : Ins.Co.Phone #: ()--
Insurance Co Name: Birth Date of Insured:
Relationship: SS# of Insured:
Name of Employer : Work Phone# : ()---
AUTHORIZATION & RELEASE INFORMATION
* I certify that I have read and understand the above information to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information on my medical history can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third party payers and /or health care practitioners. I authorize and request my insurance company to pay directly to the dentist benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual dental bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
* I consent to the making of photos and x-rays before, during, and after treatment and the use of them by the dentist in scientific papers or demonstrations.
* I certify that I have read, or have been read to me, the contents of this form and do realize the risks and limitations involved.
*Signature
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Testimonial
Clint Bruyere, DDS
5 Clint Bruyere, DDS - reviews
"I have been more than pleased with your office and staff. You have gone above and beyond to get me in as a new patient and take care of the issues I had in a very efficient and timely manner. You all made me feel very comfortable and welcome and I appreciate all of you for your kindness and sincere concern. Thank You."
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Review Md