Registration | Todays Dentistry, LLC

Registration

Welcome! Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions, or need assistance, please give us a call at: 931-456-2236

Personal Information

Date:
Birthdate:
SSN#:
Email:
Name:
Wishes To Be Called:

Gender: Male Female

Status: Minor Single Married Divorced Widowed Separated

Address:
City:
State:
Zip:
Employer:
Occupation:
Referred By:
Home Phone:
Work Phone:
Cell Phone:

Calling Preference: Home Work Cell

Best Time To Contact:

Responsible Party

Who is responsible for the account?

Name:
Relationship To Patient:
Birthdate:
Drivers License #:
SSN#:
Email:
Address:
City:
State:
Zip:
Employer:
Occupation:
Work Phone:
Home Phone:
Cell Phone:

Emergency Contact

In the event of an emergency, who should we contact?

Name:
Relationship:
Work Phone:
Home Phone:

Primary Insurance

Name Of Insured:
Relationship To Patient:
Insured's Birthdate:
SSN#:
Employer:
Date Employed:
Occupation:
Insurance Company:
Group #:
Employee/Cert #:
Ins. Co. Address:
Deductible:
Amount Already Used:
Max. Annual Benefit:

Primary Insurance

Authorization and Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or other health practitioners.

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

I Understand And Authorize: Yes No

Financial Arrangements

For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment

Payment Type: Cash Personal Check Credit Card - MC Credit Card - Visa I wish to discuss the dental office's policy