Mark L Davies, DDS, FAGD
1664 Village Green • Crofton, MD 21114 • (301) 261-3800 • (410) 721-8688
www.drmarkdavies.com

Registration/Dental Insurance Form

Patient Information
Last Name
First Name
Middle Initial
Dental Insurance
Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with
Name of Insurance Company(ies)
and assign directly to Dr. Davies 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 to 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 continue for as long as I am a patient of Dr. Davies.
Signature of Patient Parent, Guardian or Personal Representative
Please Print Name of Patient Parent, Guardian or Personal Representative
Date
Relationship to Patient

Phone Numbers
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

(Mr.,Mrs.,Ms.,Dr., by first or nickname)
Clear Signature
Accept Signature
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