Platinum Dental, Inc.

 Patient Registration

				

Patient’s Name: ______________________________________

Mr. ____    Mrs. ____     Ms. ____    Miss ____      Dr. ____    Other ____

Name you prefer to be address by: _______________________________

Street Address:  ______________________________________________

City:  ________________________ State:  ________ Zip:  ____________

Employer Name:  _____________________________________________

Employer Address:  ___________________________________________

City:  ________________________ State:  ________ Zip:  ____________

Length of Employment: ____Mos./Yrs.  Occupation:  ________________

If patient is a child, Parent’s Name:  ______________________________

School’s Name:  ______________________________________________

Grade:  ______________________ Full Time Student: Yes ____ No ____	
										       
Please complete the following confidential information.			               

 Home Phone:  (             )________________________                                                                           

 Work Phone:   (             )________________________                                       

 Cell Phone:      (             )_______________________                                                           

 E-mail:______________________________________                                                                         	

Social Security #:  _________-_______-__________

Birth Date:           /          /             Male __ Female __

Married ___ Single ____ Divorced ____ Other _____

Person to contact in case of an emergency:

Name:  ____________________ Relation:  ________ 

Phone: (               )____________________________                                                                      

Alternate Phone:  (               )____________________                                         

Name of Person Responsible for this Account:  __________________________________________________________________

Please complete the following information in full if you would like us to assist you with your insurance claims.

Primary Dental Insurance Company:  __________________________________________Phone (              )_____________________ 

Group/Policy #: _____________________________ID #:  _________________________Subscriber is: Self ______ Spouse _______

Secondary Dental Insurance Company: ________________________________________ Phone (              )_____________________

Group/Policy #: _____________________________ID#: __________________________Subscriber is: Self ______ Spouse _______

Medical Insurance Company:________________________________________________  Phone (              )_____________________

Group/Policy #:_____________________________ ID#: __________________________Subscriber is: Self ______ Spouse _______

If the insurance coverage is through your spouse, please provide us with Spouse’s Name:_____________________________________

Spouse’s Employer Name:                                                                                  Phone: (              )                                           ext.:________            

Spouse’s Employer Address:  ____________________________________________________________________________________

Spouse’s Social Security Number: _________________________________ Spouse’s Birth Date:______________________________

How did you hear about our office? (Please circle): Banner  Flyer  Internet   Website   Yellow Pages   Patient   Doctor   Other

Whom may we thank for referring you to us? ____________________________________________________________
 
I hereby authorize the release of any information required to complete my insurance claims and further authorize payment directly to Platinum Dental, Inc. for any benefits otherwise payable to me for their professional services. A copy of this authorization may be used in place of the original. To avoid misunderstanding regarding insurances, we wish our patients to know that all services rendered are charged directly to the patient and that the patient is responsible for all fees not paid by the insurance company.

Signature:_____________________________________________		Date:__________________________			(Patient/Responsible party)
Patient Registration/Revised March 2009