Print Patient Registration

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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______ ________________________