Dental Registration And History

  • PATIENT INFORMATION

  • DENTAL INSURANCE

  • ASSIGNMENT AND RLEASE


    I, the undersigned certify that I (or my dependent) have insurance coverage with

  • and assign directly to Dr

  • 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

  • PHONE NUMBERS

  • Best time to reach you
  • IN CASE OF EMERGENCY, CONTACT

    (Specify someone who does not live in your household.)

  • Work/Cell Phone

  • Check “Yes” or “No” where indicated for all that apply:

  • HEALTH HISTORY

  • Place a mark on “Yes” or “No” to indicate if you have had any of the following:

  • MEDICATIONS

  • ALLERGIES

  • UPDATES


    ( To be filled in at future appointments)