Patient Registration Patient Registration About You: Date* Last Name * First Name * Preferred Name Address * City * State * ZIP Code * Home Phone * Work Phone Cell Phone Email * Gender MaleFemaleOther Social Security Number * Date of Birth * Marital Status SingleMarriedDivorcedWidowed Employer Who Can We Thank for Referring You? Emergency Contact: Last Name First Name Phone Relationship to Patient Responsible Party: Same as above Last Name First Name SS Number Birth Date Employer Phone Insurance Info Self-Paying Insurance Company Insurance Number Claims Address Payer Number Subscriber Name Subscriber Social Security Number Subscriber Date of Birth Secondary Insurance Info Insurance Company Insurance Number Claims Address Payer Number Subscriber Name Subscriber Social Security Number Subscriber Date of Birth Consent & Authorization I hereby authorize Oceanspray Dental Health to perform procedures including but not limited to giving anesthesia and medications, making radiographs and photographs to be used in professional presentations or journals, performing oral, head and neck examination, removing and restoring teeth, and any necessary prosthodontics therapy. I certify that I have read and fully understand the above consent to treatment. I authorize release of any information necessary to process my insurance claim and also hereby authorize payment of insurance benefits to Oceanspray Dental Health. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my or my dependents' behalf. A copy of this signature is valid as the original. Your name and signature also indicate that you have received a copy of our Notice of Privacy Practices on the date indicated. Signature of Patient or Parent (if minor) Date
