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Patient Registration

Patient Information

 Title   Patient's Name  Social Security Number 
 Name of Spouse    Spouse's Social Security Number
 If a Child, Parent's Name
 Street Address                 
 City State   Zip Code
                                                                              
                                                                                Please check preferred modes of contact

Home Phone Work Phone Cell Phone Email
 
 Birth Date    
Marital Status   Married  Single  Separated  Divorced  Widowed 
        
Sex   Male      Female


                                                                                                      Employment

Patient Employer              Phone
Employer Address        
Present Position              How long held 
Spouse Employer             Phone
Present Position              How long held 

Whom may we thank for referring you to Glick Dental Associates?

Financial/Insurance Information
PLEASE NOTE: Federal and State regulations require that you report all dental and medical insurance coverage under which you may be eligible for benefits. Failure to do so will result in the forfeiture of benefits under any policy.

Dental Insurance Company No. 1 
Plan number   Individual Plan Family Plan (Coverage for spouse and children)
Dental Insurance Company No. 2 
Plan number   Individual Plan Family Plan (Coverage for spouse and children)
Medical Insurance Company        
Plan number   Individual Plan Family Plan (Coverage for spouse and children)

 

INSURANCE: To avoid misunderstanding regarding dental insurance, we wish our patients to know that all professional services rendered are charged directly to the patient and that patients are personally responsible for payment of fees. We will prepare necessary forms or reports to help you obtain your benefits from insurance companies contingent upon your advance payment of your either full (or, in some cases partial) payment of the bill. We do not render any services on the basis that insurance companies will pay our fees. Each fee is individual and based upon a patients particular needs. If you are covered under a discount or pre-paid dental plan, co-payment must be made when treatment is rendered. Accounts that are past due are subject to interest and collection fees.

APPOINTMENTS: To avoid any misunderstanding regarding failed or cancelled appointments, a minimum charge is often required by insurance companies if appointments are cancelled within 24 hours.   Our office is maintained on a schedule. Once an appointment is made, please remember that time is reserved for you. When you fail to notify us of your inability to keep an appointment, another patient in need of dental care and waiting for an appointment is prevented from receiving treatment. (Pressing submit button will constitute a signature and will submit your information to Glick Dental Associates).

   

Please note that if you receive an error message when submitting this form it can be alternatively printed and faxed to 440 349-0558.