Adult Registration Form

Patient Information

 
 
 
Patient Birth Date
 
 

 
 
​​

Spouse / Partner Information


Birth Date

Emergency Contact Information

 
 
 
 
 

Insurance Information

Primary Insurance Company
Birth Date

Secondary Insurance

Birth Date

Dental History


If yes, when?

Have you ever had an injury to (select all that apply)



 
 
Do you currently have or ever had any of the following habits (check all that apply)





 Medical History

Are you currently being treated by a physician?
Date of Last Visit

 


Check if you have or have ever had any of the following:
​​​










































Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Today's Date