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TRANSCRIPT
TIME 11:14 AM
PATIENT REGISTRATION
DATE 4/3/2014
Patient Information
Additional Comments: A,:
B,:
C,:
D,:
E,:
F,:
G,:
Primary Insurance Information
Responsible Party (if someone other than the patient)
ID:
First Name:
Policy Holder
Responsible Party
Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder
Section 2
Full Time Part Time Retired
Section 3
Address 2:
State / Zip:
Sex: Marital Status: Married Single Divorced Separated Widowed
E-mail: I would like to receive correspondences via e-mail.
Address:
City:
MaleOther
Female
Birth Date:
Full Time Part Time
Employment Status:
Student Status:
Medicaid ID: Pref. Dentist:
Employer ID: Pref. Pharmacy:
Carrier ID: Pref. Hyg.:
Name of Insured: Self Spouse Child Other
First Name:
Address 2:
First Name:
Address:
Home Phone:
Birth Date: Drivers Lic:Soc Sec:
Work Phone: Ext: Cellular:
City, State, Zip: Pager:
Last Name: Middle Initial:Last Name:
Insured Soc. Sec: Insured Birth Date:
Secondary Insurance Information
Name of Insured: Self Spouse Child Other
Rem. Deduct: .00
Employer:
Address:
Address 2:
City,State,Zip:
Ins. Company:
Address:
Address 2:
City,State,Zip:
Rem. Benefits: .00
Insured Soc. Sec: Insured Birth Date:
Employer:
Address:
Address 2:
City,State,Zip:
Ins. Company:
Address:
Address 2:
City,State,Zip:
Rem. Benefits: .00 Rem. Deduct: .00
Soc. Sec:Age: Drivers Lic:
Chart ID:
Home Phone: Work Phone:
Pager:
Ext: Cellular:
Last Name: Middle Initial:
Patient Is:
Relationship to Insured:
Relationship to Insured:
Preferred Name:
FOR YOUR INFORMATION
Because we care about our patients, we want you to be informed of the special ways we
care for our patients.
� As a courtesy to our patients, we accept assignment of most dental insurance
plans. We will also file your claims for you. Primary and Secondary.
We can only ESTIMATE your dental benefits from the information given to
us by your insurance company. We can not guarantee that they will pay
accordingly. It is likely and probable that your coverage will be less than
expected
Please sign as acknowledgment___________________________
� Any discrepancy is between you and your insurance company. Your estimated co-
pay for treatment will be collected when you arrive for that visit. Unless it is for
Surgery then your co-pay will be collected 3 days prior to your appointment date.
Any balance remaining, after the insurance has paid us, will be your responsibility
and we will send you a bill.
� As a courtesy to ALL our patients, we ask that you be on time for your
appointments. If you are unable to keep your appointment, we require 24 hour
notice so that we may give your reserved time to another patient and avoid
charging you for a missed appointment.
� During treatment, conditions can be discovered that require additional or different
treatment. Any changes or additional treatment and fees will first be discussed
with you.
� When treating your children, we ask that you wait in our reception area. Over 10
years of experience and our training has proven that children will have a better
dental experience without their parents in the room. We want to build trust
between our staff and your child, in order to make treatment fun, easy and fast.
Patient/ Parent/ Guardian_________________________________________________
Date:_________________________________________________________________
PATIENT INFORMATION FOR ABILENE DENTAL CARE
Patient Name: _________________________________________________________
Email address: _________________________________________________________
Preferred Name/ Nick Name: _____________________________________________
Gender: Date of Birth: _________________
o Female
o Male Age: ________________________
Please check one:
o Child
o Single
o Married
o Divorced
o Widow
Occupation/ Employed by: _______________________________________________
Are you a student? Yes or No What school do you attend? _________________
How did you hear about us? _______________________________________________
o Phonebook
o Google
o Facebook
o Friend, if so whom can we thank? _______________________________
o Other: _____________________________________________________
Are there other family members treated at Abilene Dental Care? Yes or No
If, Yes Please list name and ages:
Spouses Name and Occupation: ______________________________________________
What is the primary concern for your visit? ____________________________________
Do you have breath odor concerns? ___________________________________________
Do your gums bleed when you brush? _________________________________________
Would you like your teeth whiter? ____________________________________________
If you can change anything about your teeth what would it be? _____________________