Patient Registration

Please Complete the Following Confidential Information

If this Appointment Is for you Start here

First Name *

Last Name *

Email Address *

Cell *

Date

M.I.

Address

City

State

ZIP

Home Phone No.

Fax

Birth Date

Age

Gender

Male

Female

Marital Status

Married

Single

Divorced

Widowed

Social Security No.

If this appointment is for your child start here

Date

Last Name

First Name

M.I.

Address

City

State

ZIP

Home Phone No.

Birth Date

Age

Gender

Male

Female

School

Grade

Social Security No.

If your child's last name and/or address are not the same as yours, fill in the top box also

DENTAL INSURANCE

PRIMARY CARRIER

Insurance Company

Group No.

Employer Name

Insured's Name

Date of Birth

Relationship To Patient

Insured's I.D. No.

Insured's Social Security No.

SECONDARY CARRIER

Insurance Company

Group No.

Employer Name

Insured's Name

Date of Birth

Relationship To Patient

Insured's I.D. No.

Insured's Social Security No.

Patient Registration

GETTING TO KNOW YOU

Is another member of your family or relative a patient at our office?

Name

Relationship

YOU WERE REFERRED TO US BY

Name

PERSON TO CONTACT FOR EMERGENCY

Name

Cell Number

Home Number

Address

City

State

ZIP

ACCOUNT INFORMATION

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT

Name

Relationship To Patient

Social Security No.

Address

City

State

ZIP

Phone Number

YOU

Name

Occupation

Employer's Name

Address

City

Phone Number

Fax Number

YOUR SPOUSE

Name

Occupation

Employer's Name

Address

City

Phone Number

Fax Number

Patient Registration

CONSENT FOR TREATMENT

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of

Name of Patient's

dental needs.

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that can ask for a complete recital of any possible complications.

4. I give consent to the doctor's or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

Patient's Signature

Use your mouse or finger to sign in the box below.

Date

Witness

Parent/Responsible Party's Signature

Use your mouse or finger to sign in the box below.

Relationship to Patient

Encino Advanced Dentistry

Encino Advanced Dentistry

Patient Registration

Patient Registration

Please Complete the Following Confidential Information

DENTAL INSURANCE

Patient Registration

GETTING TO KNOW YOU

ACCOUNT INFORMATION

Patient Registration

DENTAL HISTORY

Patient Registration

MEDICAL HISTORY

Patient Registration

CONSENT FOR TREATMENT

Encino Advanced Dentistry

Encino Advanced Dentistry

Patient Registration

Patient Registration

Please Complete the Following Confidential Information

DENTAL INSURANCE

Patient Registration

GETTING TO KNOW YOU

ACCOUNT INFORMATION

Patient Registration

DENTAL HISTORY

Patient Registration

MEDICAL HISTORY

Patient Registration

CONSENT FOR TREATMENT

Forms Sent!