Patient Registration - Richards Dental Care

First Name:

Middle Initial:

Last Name:

Patient is:

Policy Holder

Responsible Party

Preferred Name:

Patient Information

Address:

Address 2:

City

State / Zip:

Cellular :

Home Phone:

Work Phone:

Ext:

Sex

Male

Female

Birth Date

day

/

month

/

year

Age :

Social Security No.

Driver License No.

Email

Would like to receive correspondences via email?

Yes

No

Would like to receive correspondences via text?

Yes

No

Section 2

Employment Status :

Full Time

Part Time

Retired

Student Status :

Full Time

Part Time

Medicaid ID :

Employer ID :

Pref. Pharmacy :

Carrier ID :

Pref. Hyg.:

Dental Insurance Information

Name of Insured :

Relationship to Insured :

Self

Spouse

Child

Other

Insured Soc. Sec :

Insured Birth Date:

day

/

month

/

year

Employer :

Ins. Company :

Address -

Address -:

Address 2 -

Address 2 -:

City, State, ZIP :

City, State, ZIP -:

Rem. Benefits :

Rem. Benefits -:

Rem. Deduct :

Rem. Deduct -:

Responsible Party (if someone other than patient)

First Name

Middle Initial

Last Name

Address

Address 2

City, State, Zip

Home Phone

Cellular

Work Phone

Ext

Birth Date

Social Security #

Driver License #

Responsible Party is also a Policy Holder for Patient

Dental Insurance Policy Holder

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