Patient Registration

  • MM slash DD slash YYYY
  • Patient's Emergency Contact

  • Patient's Responsible Party

    *If someone other than patient
  • Patient's Dental Insurance (Primary)

    Please Note: Your insurance is a contract between you and your insurance carrier. It is your responsibility to know the terms of your policy. i.e. frequency limitations, deductibles, etc. and to inform our office of any changes to your dental insurance. We file claims as courtesy and will accept assignment of benefits when possible, but you will be responsible for all fees regardless of insurance coverage. Please ask if you have any questions.
  • MM slash DD slash YYYY
  • Patient's Dental Insurance Secondary

  • MM slash DD slash YYYY
  • I hereby authorize payment directly to Plage Dentistry of any benefits otherwise payable to me under my dental insurance plan. I understand that I am responsible for all fees for professional services rendered to me or my dependents. I hereby authorize Plage Dentistry to administer any medications and perform any diagnostic and therapeutic procedures as may be necessary for my dental care. I will not hold Plage Dentistry or any member of their staff responsible for any errors or omissions that I may have made in the completion of this form and the medical history form. The information on this page and the medical history are current to the best of my knowledge.

If you don’t want to fill online form you can download it here.

Next Form: Medical History Form