Patient Registration Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No Person responsible for account*Other parental consent required* Yes No Mother’s name*Business Tel*Father’s name*Business Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code In case of emergency, please notify:Name*Relation*Home Phone*Cell Phone*Work Phone*Contact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email Whom may we thank for referring you?*Are any other members of your family patients at our practice?* Yes No Please list all family members*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber*Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment*Insurance Company*Policy/Group #*Certificate/ID #*I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes I agree to receive emails with related information and updates. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.