Patient Registration Form Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we’ll be happy to assist you.Date Date Format: MM slash DD slash YYYY Patient InformationName First Middle Last Sex: Male Female Date of Birth (mm/dd/yyyy): Date Format: MM slash DD slash YYYY Marital Status:--select--MarriedSingleSeparatedWidowedDivorcedSocial Security #:Home Phone/ Work Phone:Cell Phone:E-mail Address: Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you a StudentYesNoFULL TIME OR PART TIME--select--Full TimeParttimeSchool NamePlease tell us where you heard about us (check all that apply): Friend or Relative (name): Our Website Search Engine (Google, etc.) NameWas our website a factor in your decision to visit our practice? Yes No Name of Spouse / Partner (or Parent, if a minor):Spouse/Partner/Parent’s Employer:Spouse/Partner/Parent Work Phone:Spouse/Partner, Parent Cell Phone as Emergency contact:Person Responsible for AccountName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Relationship to Patient:Social Security #:Drivers Licence State & #:Holder of Dental Insurance for Patient:Home Phone:Work Phone:Cell Phone:E-mail Address: Billing Address: Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employer’s Name:Occupation:Insurance Information Primary InsuranceInsurance Holder’s Name:Date of Birth (mm/dd/yyyy): Date Format: MM slash DD slash YYYY Relationship to Patient:Employer:Member ID:Group ID:Insurance Company Name:Insurance Company Phone:Insured’s SSN:Insurance Company Address: Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Secondary Insurance:Insurance Holder’s Name:Date of Birth (mm/dd/yyyy): Date Format: MM slash DD slash YYYY Relationship to Patient:Employer:Member ID:Group ID:Insurance Company Name:Insurance Company Phone:Insured’s SSN:Insurance Company Address: Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Authorization All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Tracey Tabor Williams, DMD to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to Tracey Tabor Williams, DMD. I permit a copy of this authorization to be used in place of the original. I give Tracey Tabor Williams, DMD, its employees, and/or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of treatment, insurance, or payment.Signature (Type your name):Date (mm/dd/yyyy): Date Format: MM slash DD slash YYYY Consent for Treatment Patient Name:Who can treatment plan be discussed with?Relationship to patient?I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the dental needs of the above-named patient. Upon such diagnosis, I authorize the doctor or designated staff to perform all recommended treatment mutually agreed upon by us and to employ such assistance as required to provide proper care. I agree to use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I have read, understood, and agree to the above treatment policy. Signature (Type your name):Date (mm/dd/yyyy): Date Format: MM slash DD slash YYYY PaymentDoes the person responsible for the account already have an account with this office? Yes No Payment MethodNotice: Payment is due at the time of service unless alternative arrangements have been made in advance. Please choose a method of payment below. Cash Check Credit Card Type:Credit Card Number:Expiration (m/y):Card Verification Code:VISA/MC/Discover: 3-digit code printed on back AmEx: 4-digit code printed on front Your credit card information is kept on file and will be used for any outstanding balances left after your copays and insurance payments have been received.Dental HygieneDo you brush your teeth? Yes No How often?Do you floss? Yes No How often?Today’s VisitDo you have any dental problems, pain, or discomfort at this time? Yes No Please describe:What is the main reason for your visit today?--select--Tooth PainCheck-upCleaningWhiteningWhat would you like to learn more about?Please Explain:Office Policies and Financial Agreement It is our policy to have a definite agreement between you, the patient, and this office concerning the payment of fees for services rendered. Prior to treatment, you will be advised of an estimated cost of treatment. If you have dental insurance, we will do our best to estimate your out of pocket expenses based on the information we gather from your insurance company. If you require more than an estimate, please let us know, and a predetermination of benefits may be sent to your insurance company on your behalf. This requires the insurance company to inform our office and you exactly what they will pay. This does delay treatment, but it is a service we offer to remove any uncertainty about your out of pocket costs. For your convenience, we accept Cash, Check, Visa MasterCard, & Care Credit. All emergency dental services or any dental services performed without previous financial arrangements with the financial staff must be paid for at the time of service. Patients Not Covered By Dental Insurance: Payment in full is expected when services are rendered. Patients Covered By Dental Insurance: We will be happy to complete the necessary forms for your dental claims as a courtesy to you. You are responsible for the entire balance regardless of your insurance coverage. We are a third-party providing dental services to you and your family. This office requires that you are responsible for your co-payment and deductibles at the time of service. We will allow 60 days for your insurance earner to reimburse us for services provided. If your insurance carrier fails to issue reimbursement within that time frame, the outstanding balance will be your responsibility and a statement will be sent or your credit card on file will be used to pay any outstanding balances. We understand that situations arise in which you may need to cancel or change your appointment due to unforeseen circumstances. We kindly request you give us as much notice as possible if you must cancel your appointment. We would prefer to have 48 hours notice so that we may attempt to arrange for another patient to be seen at that time. We do not double book appointments and your appointment time is reserved exclusively for you. If an appointment is cancelled, without at least a 24 hour notice, you will be charged a $75.00 cancellation fee. Patients that miss their appointment without calling to cancel will be considered a “No Show” and will also be charged a $75.00 fee. These fees will not be covered by your insurance company, and must be paid before the next appointment is made. We value our professional relationships and believe effective communication and mutual respect is of the utmost importance. Any questions about this policy may be directed to the front office staff. In consideration for the professional services rendered to me, I agree to pay for those services in full. I agree that a $10.00 late fee per month can be added to any account balance that is over 90 days. In the event that my account is turned over to a collection agency, I agree to pay any court costs and attorney fees which may be associated with my account. I grant my permission for you to telephone me at home or work to discuss matters related to this form. I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL AND OFFICE POLICY AGREEMENT.Signature (Type your name):Date (mm/dd/yyyy): Date Format: MM slash DD slash YYYY Patient Dental HistoryName of Previous Dentist and LocationDate of Last Exam Date Format: MM slash DD slash YYYY Authorization and Release l certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. l understand that providing incorrect information can be dangerous to my health. l 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 payers and/or 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.Signature of patient (or parent/guardian if minor)SignatureDate Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
