Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
About You
Title : Mr Mrs Ms Dr
Patient Name :
Last Name*
Middle Name First Name*
Prefer to be called : Sex : Male Female
Birthday:*
Age: SSN:
Marital Status: Single Married Partnered Widowed
Divorced/Separated
Home Address:*
City
State
Zip
Apt#
Home Phone:* ()--
Cell Phone:* ()--
Work Phone: ()---
E-mail:*
Driver’s License:
Employer:
Employer Address: City
State Zip
Apt#
How long there?
How long there?
Occupation:
Previous dentist:
Present dentist:
Where & when are best times to reach you?
How did you hear about us?*
Have you visited our website? Yes No
Whom may we Thank for referring you?
Other family members seen by us:
Person responsible for account:*
Relationship to patient:
Spouse Information
His / Her name :
Employer :
Birthday:
SSN:
Work Phone: ()---
Driver’s License:
Relative or friend not living with you
His / Her name:*
Relationship :
Home Phone:* ()--
Work Phone: ()---
Insurance Information
Primary Insurance
Dental coverage? Yes No
Insurance Co. name:
Address:
City
State
Zip
Phone: ()--
Group#:
Insured’s name :
Relationship :
Birthday:
SSN:
Insured’s employer:
Address:
City
State
Zip
Secondary Insurance
Dental coverage? Yes No
Insurance Co. name:
Address:
City
State
Zip
Phone: ()--
Group#:
Insured’s name :
Relationship :
Birthday:
SSN:
Insured’s employer:
Address:
City
State
Zip
Assignment and Release
(Please Fill your Insurance Details)
* I, the undersigned, have insurance with name of insurance company(ies) and assign directly to Dr. Jamil J. Alkhoury, D.D.S. all 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submission whether manual or electronic.
* I also understand and agree that there will be a charge of $ 100 in the event that I fail to inform Dr. Alkhoury or his office prior to a minimum of 24Hr of the appointment, of my inability to keep with the appointment


*Signature
Date
Dentists Brentwood - A happy client
These video testimonials are from actual patients treated by Dr. Alkhoury after their consent to display their testimonials , results are not the same and may vary.
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Testimonials
Rating : 5 Dentists Brentwood - 5 Star Rating Review
"The best dentist and office staff in the world!! I drive 4 hours from Northern Nevada to Brentwood for my dental needs. They are always so gentle and very interested in you. No pain ever and I had several crowns, root canals and deep cleanings done and not once did I experience pain and even afterward no soreness or pain. It may sound funny to say, But I love my dentist and his office staff!!"
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