Patient Registration

INFORMATION
BILLING
INSURANCE
MEDICAL ALERTS
QUESTIONNAIRE
CONSENT LETTERS
REVIEW

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Patient personal information Page 1 of 7

Please enter all required fields.

Title

Preferred Name

Preferred name contains potentially dangerous scripts.

Last name *

Please enter patient last name.

Last Name contains potentially dangerous scripts.

First name *

Please enter patient first name.

First Name contains potentially dangerous scripts.

Address*

Please enter patient address.

City *

Please enter patient city

State

Zip *

Please enter patient zip code

Please Select

Email*

Please enter a valid email address.

Please enter email.

{{DateFormateText}} *

Please enter a valid date.

Age

Health Care Guardian Name

Health Care Guardian Phone #

Please enter health care guardian phone number in proper format.

Marital Status

Sex*

Please select Sex.

Home #*

Please enter patient home phone number.

Please enter home phone number in proper format.

Please enter patient phone number in either home or cell or work.

Work #*

Please enter patient work phone number.

Please enter work phone number in proper format.

Cell #*

Please enter patient cell phone number.

Please enter cell phone number in proper format.

Drive Lic

Emergency Contact

Emergency Phone #

Please enter emergency phone number in proper format.

Student

{{SetSSNTextByCulture}}*

Please enter valid {{SetSSNTextByCulture}}.

Please enter {{SetSSNTextByCulture}}.

School name

Referral Type*

Please select Referral Type.

Referred By

Preferred Language

Billing Page 2 of 7

Please enter all required fields.

Is patient responsible for paying bills? Yes No

Title

Preferred Name

Last name *

Please enter responsible party last name.

First name *

Please enter responsible party first name

Address*

Please enter responsible party address.

City*

Please enter responsible party city.

State

Zip *

Please enter responsible party zip code.

Please Select

Email*

Please enter a valid email address.

Please enter email.

{{DateFormateText}} *

Please enter a valid date.

Age

Marital Status

Sex*

Please select Sex.

Home #*

Please enter patient home phone number.

Please enter home phone number in proper format.

Please enter patient phone number in either home or cell or work.

Work #*

Please enter patient work phone number.

Please enter work phone number in proper format.

Cell #*

Please enter patient cell phone number.

Please enter cell phone number in proper format.

Drive Lic

{{SetSSNTextByCulture}}*

Please enter valid {{SetSSNTextByCulture}}.

Please enter {{SetSSNTextByCulture}}.

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insurance Page 3 of 7

Please note: setting Primary Insurance as "No" will clear all entered information for both insurance.

Do you have Primary Dental Insurance Yes No

Group No/Name

Insurance Name*

Please enter primary Insurance Name.

Insurance Phone

Please enter phone number.

Please enter phone number in proper format.

Employer Name

Subscriber/Policy Holder First Name*

Please enter Subscriber/Policy Holder First Name.

Subscriber/Policy Holder Last Name*

Please enter Subscriber/Policy Holder Last Name.

Subscriber/Policy Holder Address

City

State

Zip

Please Select

Relationship to Patient

Please enter a valid date.

{{SetSubTextByCulture}}*

Please enter primary {{SetSubTextByCulture}}.

Please enter valid primary {{SetSubTextByCulture}}.

Upload Insurance Card Image

{{InsuranceTabData.insuranceImage == null? "No File Chosen": InsuranceTabData.insuranceImage.name}}

No Image Uploaded

File Size exceeds 2MB. Please select a smaller file.

Only JPG, PNG, GIF, and BMP formatted images are accepted.

Insurance Card Specifications

Only JPG, PNG, GIF, and BMP formatted images are accepted.
Image size is a maximum of 2MB.
The optimal image size is 400x200 (2:1 ratio). Use of different dimensions may distort the display of the image.

Do you have Secondary Dental Insurance Yes No

Group No/Name

Insurance Name*

Please enter secondary Insurance Name.

Insurance Phone

Please enter phone number.

Please enter phone number in proper format.

Employer Name

Subscriber/Policy Holder First Name*

Please enter Subscriber/Policy Holder First Name.

Subscriber/Policy Holder Last Name*

Please enter Subscriber/Policy Holder Last Name.

Subscriber/Policy Holder Address

City

State

Zip

Please Select

Relationship to Patient

Please enter a valid date.

{{SetSubTextByCulture}}*

Please enter secondary {{SetSubTextByCulture}}.

Please enter valid secondary {{SetSubTextByCulture}}.

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Medical Alerts No to all med alerts Page 4 of 7 Page 2 of 4

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Dental Questionnaire Page 5 of 7Page 3 of 4

Medical Questionnaire

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Consent Letters Page 4 of 5Page 6 of 7

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Patient personal information Page 7 of 7

Title

Preferred Name

Last name

First name

Address

City

State

Zip

Age

Health Care Guardian Name

Health Care Guardian Phone

Marital Status

Sex

Home #

Work #

Cell #

Drive Lic

Emergency Contact

Emergency Phone

Student

*********

Referred By

Referral Type

School name

Preferred Language

Is patient responsible for paying bills?

Billing

Title

Preferred Name

Last name

First name

Address

City

State

Zip

Age

Marital Status

Sex

Home #

Work #

Cell #

Drive Lic

*********

insurance

Do you have Primary Dental Insurance

Group No/Name

Insurance Name

Insurance Phone

Employer Name

Subscriber/Policy Holder First Name

Subscriber/Policy Holder Last Name

Subscriber/Policy Holder Address

City

State

Zip

Relationship to Patient

SubID

{{SetSSNTextByCulture}}/SubID

Insurance Card Image

Do you have Secondary Dental Insurance

Group No/Name

Insurance Name

Insurance Phone

Employer Name

Subscriber/Policy Holder First Name

Subscriber/Policy Holder Last Name

Subscriber/Policy Holder Address

City

State

Zip

Relationship to Patient

SubID

{{SetSSNTextByCulture}}/SubID

*********

Medical Alerts

Dental Questionnaire

Medical Questionnaire

Consent Letters

Patient signature

Clear

Draw your signature

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