TIME 11:14 AM

PATIENT REGISTRATION

DATE 4/3/2014

Patient Information

Additional Comments: A,:

B,:

C,:

D,:

E,:

F,:

G,:

Primary Insurance Information

Responsible Party (if someone other than the patient)

ID:

First Name:

Policy Holder

Responsible Party

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Section 2

Full Time Part Time Retired

Section 3

Address 2:

State / Zip:

Sex: Marital Status: Married Single Divorced Separated Widowed

E-mail: I would like to receive correspondences via e-mail.

Address:

City:

MaleOther

Female

Birth Date:

Full Time Part Time

Employment Status:

Student Status:

Medicaid ID: Pref. Dentist:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg.:

Name of Insured: Self Spouse Child Other

First Name:

Address 2:

First Name:

Address:

Home Phone:

Birth Date: Drivers Lic:Soc Sec:

Work Phone: Ext: Cellular:

City, State, Zip: Pager:

Last Name: Middle Initial:Last Name:

Insured Soc. Sec: Insured Birth Date:

Secondary Insurance Information

Name of Insured: Self Spouse Child Other

Rem. Deduct: .00

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00

Insured Soc. Sec: Insured Birth Date:

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00 Rem. Deduct: .00

Soc. Sec:Age: Drivers Lic:

Chart ID:

Home Phone: Work Phone:

Pager:

Ext: Cellular:

Last Name: Middle Initial:

Patient Is:

Relationship to Insured:

Relationship to Insured:

Preferred Name:

FOR YOUR INFORMATION

Because we care about our patients, we want you to be informed of the special ways we

care for our patients.

� As a courtesy to our patients, we accept assignment of most dental insurance

plans. We will also file your claims for you. Primary and Secondary.

We can only ESTIMATE your dental benefits from the information given to

us by your insurance company. We can not guarantee that they will pay

accordingly. It is likely and probable that your coverage will be less than

expected

Please sign as acknowledgment___________________________

� Any discrepancy is between you and your insurance company. Your estimated co-

pay for treatment will be collected when you arrive for that visit. Unless it is for

Surgery then your co-pay will be collected 3 days prior to your appointment date.

Any balance remaining, after the insurance has paid us, will be your responsibility

and we will send you a bill.

� As a courtesy to ALL our patients, we ask that you be on time for your

appointments. If you are unable to keep your appointment, we require 24 hour

notice so that we may give your reserved time to another patient and avoid

charging you for a missed appointment.

� During treatment, conditions can be discovered that require additional or different

treatment. Any changes or additional treatment and fees will first be discussed

with you.

� When treating your children, we ask that you wait in our reception area. Over 10

years of experience and our training has proven that children will have a better

dental experience without their parents in the room. We want to build trust

between our staff and your child, in order to make treatment fun, easy and fast.

Patient/ Parent/ Guardian_________________________________________________

Date:_________________________________________________________________

PATIENT INFORMATION FOR ABILENE DENTAL CARE

Patient Name: _________________________________________________________

Email address: _________________________________________________________

Preferred Name/ Nick Name: _____________________________________________

Gender: Date of Birth: _________________

o Female

o Male Age: ________________________

Please check one:

o Child

o Single

o Married

o Divorced

o Widow

Occupation/ Employed by: _______________________________________________

Are you a student? Yes or No What school do you attend? _________________

How did you hear about us? _______________________________________________

o Phonebook

o Google

o Facebook

o Friend, if so whom can we thank? _______________________________

o Other: _____________________________________________________

Are there other family members treated at Abilene Dental Care? Yes or No

If, Yes Please list name and ages:

Spouses Name and Occupation: ______________________________________________

What is the primary concern for your visit? ____________________________________

Do you have breath odor concerns? ___________________________________________

Do your gums bleed when you brush? _________________________________________

Would you like your teeth whiter? ____________________________________________

If you can change anything about your teeth what would it be? _____________________