Patient Registration

Name*
First Last
Marital Status*
Preferred Name
Birth Date*
MM slash DD slash YYYY
Gender*
- Male
- Female
Social Security
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Email
Employer
Who may we thank for referring you to our practice?
Patient's Emergency Contact
Name of Contact*
Relationship*
Phone*
Patient's Responsible Party
*If someone other than patient
Name
First Last
Relationship to Patient
Home/Cell Phone
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.
Name of Policy Holder
First Last
Name of Insurance Company
Birth Date of Policy Holder
MM slash DD slash YYYY
Subscriber or ID#
Group#
Employer
Phone
Patient's Dental Insurance Secondary
Name of Policy Holder
First Last
Name of Insurance Company
Birth Date of Policy Holder
MM slash DD slash YYYY
Subscriber or ID#
Group#
Employer
Phone
Signature*
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.

Patient's Emergency Contact

Patient's Responsible Party

Patient's Dental Insurance (Primary)

Patient's Dental Insurance Secondary

Next Form: Medical History Form

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