Patient Registration Form
0% Patient Info
Dental Insurance
Assignment and Release
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
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)
Dental History
Place a mark on "Yes" or "No" to indicate if you have had any of the following:
Health History
Place a mark on "Yes" or "No" to indicate if you have had any of the following:

Women:


Medications