Dental Registration & History

Patient Information
Date*
MM slash DD slash YYYY
Patient Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Sex*
- Male
- Female
Age*
Birthdate*
Marital Status*
- Single
- Married
- Widowed
- Seperated
- Divorced
Patient SS#*
Occupation*
Whom may we thank for referring you?

Employer
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone

Assignment & Release
I, the undersigned certify that I (or my dependent) have insurance coverage with the above insurance and assign directly to BRANDI HOWARD-STICKEL all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all 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.
Signature*

Contact Information
Home*
Work
Cell*
Email
Best time to reach you*
In Case of Emergency, Contact:

Specify someone who does not live in your household.
Name*
First Last
Relationship*
Home*
Work/Cell*

Sign Below
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature*
Phone
This field is for validation purposes and should be left unchanged.

Patient Information