[Secure Form] Patient Registration

Section 2 of 7 in this document

Page 2 of 6

Person Responsible for Account

First Name

Last Name

Social Security Number

Date of Birth

Employer

Mailing Address

City

State

Zip

Relation to Patient

Self

Parent/Guardian

Home Phone

Cell Phone

Work Phone

Section 3 of 7 in this document

Page 3 of 6

Primary Dental Insurance Information

Primary Dental Insurance Plan Name

Phone

Plan ID Number

Address

City

State

Zip

Employer

Group Number

Group Name

Insured Party First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Mailing Address

City

State

Zip

Relation to patient

Cell Phone

Work Phone

Relationship to Primary Dental Insured Party

Self

Spouse

Child

Dependent

Parent

Other

Section 4 of 7 in this document

Page 4 of 6

Secondary Dental Insurance Information

Secondary Dental Insurance Plan Name

Phone Number

Plan ID Number

Address

City

State

Zip

Employer

Group Number

Group Name

Insured Party First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Secondary Dental Insured Party

Self

Spouse

Child

Dependent

Parent

Other

Section 5 of 7 in this document

Page 5 of 6

Medical Insurance Information

Medical Insurance Plan Name

Phone Number

Medical Plan ID Number

Address

City

State

Zip

Employer

Group Number

Group Name

Insured Party First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Medical Insured

Self

Spouse

Child

Dependent

Parent

Other

General Patient Information

Patient Name: Suffix

Relation to Patient

Gender

Race

Is billing address different from physical address?

Marital Status

HIPPA Permission

Person Responsible for Account

Relation to Patient

Primary Dental Insurance Information

Relationship to Primary Dental Insured Party

Secondary Dental Insurance Information

Relationship to Secondary Dental Insured Party

Medical Insurance Information

Relationship to Medical Insured

Patient Medical History

Allergies

Have you or any relative had a life-threatening reaction to anesthesia?

Are you pregnant or nursing?

Do you have or have had these ailments?

Have you had any serious illness, operation, or been hospitalized in the last five years?

Have you had a cold or sore throat in the past two weeks?

Are you wearing contact lenses?

Are you wearing a removable dental appliance?

Do you smoke?

Do you have any disease, condition, or problem not listed above that you think we should know about?

Have you ever taken medication for osteoporosis at any time in your life?

Have you ever used a CPAP machine or been diagnosed with sleep apnea?

Do you use marijuana in any form-medical or recreational?

Race