Registration Form

    PATIENT NAME :

    *

    PREFERRED NAME :

    *

    FAMILY MEMBERS SEEN BY US :

    ADDRESS :

    CITY :


    STATE :


    ZIP :

    HOME PHONE :

    WORK PHONE :

    CELL PHONE :


    EMAIL ADDRESS :

    *

    PREFERRED METHOD OF CONTACT :

    PhoneEmailContact

    BIRTHDATE :

         GENDER :

    MaleFemale

    SOC. SEC. #

    MARITAL STATUS :

    MarriedSingleDivorcedSeparatedOther

    EMPLOYER :

    SPOUSE :

    EMPLOYER :

    EMERGENCY CONTACT PERSON :

    PHONE :

    REFERRED BY :

    INSURED OR RESPONSIBLE PARTY INFORMATION

    NAME :

    RELATIONSHIP :

    ADDRESS :

    CITY

    STATE :

    ZIP :

    SOC. SEC. # :

    PHONE # :

    BIRTHDATE :

    DENTAL INSURANCE CO. :

    ADDRESS :

    CITY

    STATE :

    ZIP :

    PHONE # :

    GROUP # :

    ID # :

    SUBSCRIBER NAME :

    BIRTHDATE :

    SOC. SEC. # :

    EMPLOYER :

    (SECONDARY COVERAGE)

    INSURANCE CO. :

    ADDRESS :

    CITY :

    STATE :

    ZIP :

    PHONE # :

    GROUP # :

    ID # :

    SUBSCRIBER NAME :

    BIRTHDATE :

    SOC. SEC. # :

    EMPLOYER :

    I understand and agree that regardless of insurance status, I am completely responsible for payment of my account for services rendered. I certify that the above information is true and correct. This signature on file is my authorization for the release of information necessary to process any of the insurance benefits. My signature authorizes that all insurance benefits are to be made payable directly to Allen Dental. This office reserves the right to verify the credit status of potential patients and/or parents
    of the patient prior to extending credit for the treatment. At the discretion of the office we may use the services of one or more credit reporting agencies.
    Signature: __________________________________________________________________                         Date: ________________________________________