loomisfamilydentist.com - PATIENT REGISTRATION

PATIENT REGISTRATION
Date

MonthDayYear
Date
Patient Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment Number:
GENDER:
Age:
Birthdate:

MonthDayYear
Date
Marital Status:

Other
Patient SS#:
Occupation:
Employer:
Email Address:
example@example.com
Whom may we thank for referring you?
Dental Insurance
Who is responsible for this account
Relationship to Patient
Insurance Co.
Group #
Is patient covered by additional insurance?
Subscriber's Name:
Birthdate

MonthDayYear
Date
SS#
Relationship to Patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have insurance coverage with Type a label and assigned directly to Dr. Navneet Kaur all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for 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.
Responsible Party Signature
Relationship
Date

MonthDayYear
Date
Phone Numbers
Patient Legal Guardian
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Ext
Cell/Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Spouse's Work
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT (Specify someone who doesn't live in your household)
Name
Relationship
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

PATIENT REGISTRATION

Dental Insurance

Phone Numbers