Swanson Dental Associates - Patient Registration

Name Name First Last
Social Security
Birth Date Birth Date / MM / DD YYYY
Sex
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email
Best ways to contact you to confirm appointments?

Best ways to contact you to confirm appointments? E-Mail Home Phone Work Phone Cell Phone Text
In case of emergency, whom should we contact?
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Is Patient a Minor?

Is Patient a Minor? Yes No
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Relationship to Patient
Parent/Guardian Address Parent/Guardian Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian Home Phone Parent/Guardian Home Phone - ### - ### ####
Parent/Guardian Work Phone Parent/Guardian Work Phone - ### - ### ####
Parent/Guardian Cell Phone Parent/Guardian Cell Phone - ### - ### ####
INSURANCE
Do you have Dental Insurance?

Do you have Dental Insurance? Yes No
PRIMARY DENTAL INSURANCE
Name of Subscriber Name of Subscriber First Last
Relation to Patient
Birth Date Birth Date / MM / DD YYYY
Social Security # or ID#
Employer
Insurance Company
Group #
Insurance Company Address Insurance Company Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Insurance Phone # Insurance Phone # - ### - ### ####
SECONDARY DENTAL INSURANCE
Name of Subscriber Name of Subscriber First Last
Relation to Patient
Birth Date Birth Date / MM / DD YYYY
Social Security # or ID#
Employer
Insurance Company
Group #
Insurance Company Address Insurance Company Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Insurance Company Phone Insurance Company Phone - ### - ### ####
Add a scan or photo of your Insurance Card. FRONT OF CARD (max file size: 2MB)

Attach Files
Add a scan or photo of your Insurance Card. BACK OF CARD (max file size: 2MB)

Attach Files
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Whom may we thank for referring you to our practice?
Referral Name/Location
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ASSIGNMENT AND RELEASE:
Draw your signature into the box below.

Draw or Type

I hereby authorize payment directly to Swanson Dental Associates for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents I authorize the above dentist and or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Clear

Full Name

I hereby authorize payment directly to Swanson Dental Associates for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents I authorize the above dentist and or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Swanson Dental Associates - Patient Registration

Swanson Dental Associates - Patient Registration

INSURANCE

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

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