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Archibald Dental Practice | Patient Registration Forms in Ontario

 

 

Archibald Dental Practice

                      Ingrid Mack Cruz D.D.S

                 Erick Esmenjaud D.D.S.

call us (909) 947-0670

 

Family Dentistry

and Orthodontics

 

 (909) 947-0670

fax (909) 673-0527

[email protected]

 

Print Patient Registration

 

 

REGISTRATION                                DATE________________                                                                                                                                              

1.-Patient_______________________________________Driver License______________

    Address________________________________City ___________________Zip______________

    Cell____________________  Phone____________________

    Sex____ Marital Status_____________ Birthdate___/___/___Age_______ S.S. #______________

    Employer__________________________Occupation_________________Phone______________           

    Address______________________________________City___________________Zip_______________

2.-Spouse____________________ Driver License________________ S.S. #_______________           

    Employer________________________Occupation_________________Phone_______________

    Address__________________________City___________________Zip_______________

3.-Responsible Party________________________________Driver License______________

    Relation to Patient______________________________S.S. #_______________

    Employer______________________Occupation_________________Phone_______________

    Address________________________City  __________________Zip_______________

4.-In case of Emergency call____________________Relationship_______________

    Phone:_______________2nd Phone:__________________________

    Address_________________ State ____City___________________Zip___________

5.-Our Practice grows by referrals from our Dental Family...

   Who may we thank  for  referring you to us for your dental  care?_____________

6.- Insurance Information:                  7.-Secondary Insurance: (if applicable)

     Insured’s Name_________________     Insured’s Name____________________________

     Insured’s Birthdate______________     Insured’s  Birthdate_________________________

     Insurance Co.____________________    Insurance Co.______________________________

     Policy #_________ Plan-ID #_______    Policy #____________ Plan-ID #______________

 

8.-I understand that I am personally responsible for the cost of my dental care.

I agree to  pay for any treatment rendered by this office, if for any reason

whatsoever my Insurance coverage denies liability.

 I will notify this office of any change in eligibility for Insurance coverage. If in default

of the above agreement on my part necessitates legal action,  I shall assume all 

responsibility for interest, and reasonable attorney fees.

    Signature_______________________________

 9.-Assignment Of Benefits

    I hereby authorize the __________________________Insurance company to make payment

    directly to  Ingrid Mack DDS    for the dental benefits otherwise payable to me. 

    The foregoing agreement is made in consideration of professional services

    beginning on _____________________.

    I hereby represent that I am of legal age and legally competent to make these assignment.

     Signature_______________________________   Witness______________________________