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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
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
Phone Numbers
Home
Work
Ext.
Cell
Spouse's Work Phone
Best time & place to reach you
IN CASE OF EMERGENCY, CONTACT
(Specify someone who does not live in your household.)
Name
Relationship
Home Phone
Work Phone
I prefer to be addressed as:
(Mr.,Mrs.,Ms.,Dr., by first or nickname)
Patient Validation:
Submit Form
Clear Signature
Accept Signature
X