Patient Registration Name* First Last Marital Status*MarriedDivorcedWidowedSinglePreferred NameBirth Date* Date Format: MM slash DD slash YYYY Gender*MaleFemaleSocial SecurityAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail EmployerWho may we thank for referring you to our practice?Patient's Emergency ContactName of Contact*Relationship*Phone*Patient's Responsible Party*If someone other than patientName First Last Relationship to PatientHome/Cell PhonePatient'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 CompanyBirth Date of Policy Holder Date Format: MM slash DD slash YYYY Subscriber or ID#Group#EmployerPhonePatient's Dental Insurance SecondaryName of Policy Holder First Last Name of Insurance CompanyBirth Date of Policy Holder Date Format: MM slash DD slash YYYY Subscriber or ID#Group#EmployerPhoneSignature*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