Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Registration

Mr. Mrs. Ms. Dr.

  Last name

  MidI

  First name
    
    

Prev. Visit :
Single Married Divorced Widowed
City
State
Zip
APT#
()- -
Mobile #:
()- -
()- -
Other Phone #:
()- -
()- - -


The Patient. The person responsible for payment.
City
State
Zip
APT#
()- - -
    



In an emergency who should be notified?
()- -


Insurance Information

Primary Dental Insurance
City
State
Zip
APT#
City
State
Zip
APT#
City
State
Zip
APT#
Insurance Authorization
By checking this box,
I authorize my insurance to pay my benefits directly to the dentist for all services rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges, whether or not paid by insurance.


Secondary Dental Insurance
City
State
Zip
APT#
City
State
Zip
APT#
City
State
Zip
APT#
Insurance Authorization
By checking this box,
I authorize my insurance to pay my benefits directly to the dentist for all services rendered.
I authorize the use of this electronic signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits.
I understand that I am financially responsible for all charges, whether or not paid by insurance.


*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)