New Patient Registration

NEW PATIENT REGISTRATION --

Address

Telephone

INSURANCE INFORMATION --

* Please present your insurance card to be photocopied for our records.

RESPONSIBLE PARTY (if patient is a minor or different from patient listed above) --

Address

Telephone

EMERGENCY CONTACT --

AUTHORIZATION --

I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child’s) health care, advice, and treatment to another dentist, or for evaluation and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to the practice and understand my insurance may pay less than the actual bill for services and that I am responsible for any services not paid or covered.

ELECTRONIC COMMUNICATIONS --

I consent to receiving HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment, etc. I understand there is no obligation to receive these electronic communications.