Patient Registration Form

Patient Information

Date

Social Security Number

Patient Name

Last Name

First Name

Middle Initial

Address

City

State

Zip

E-mail

Gender: M F

Age:

Birthdate:

Married

Widowed

Single

Minor

Separated

Divorced

Partnered for years

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone:

Spouse's Name

Birthdate

SS#

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Insurance Policy Holder

Relationship to Patient

Insurance Co.

Group#

Patient ID#

Is patient covered by additional insurance? Y N

Subscriber's Name

Birthdate

SS#

Relationship to Patient

Insurance Co.

Group#

Patient ID#

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