Patient Registration — Eastgate Family Dental

Eastgate Family Dental

Grand Rapids, Michigan

2003 Burton St SE · Grand Rapids, MI 49506
Phone: (616) 245-9830 · Fax: (616) 245-5026
www.eastgatefamilydental.com

Patient Registration

Patient Information

Last Name

First Name

Date of Birth

Preferred Name / Nickname

Sex

Social Security # (optional)

Home Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email Address

Marital Status

Employer / School

Occupation

Spouse / Partner Name

Spouse Date of Birth

Spouse SS# (optional)

Who may we thank for referring you?

Person Responsible for This Account (if different)

Emergency Contact

Emergency Contact Name

Relationship

Phone

Dental Insurance — Primary

Insurance Company Name

Phone

Subscriber Name (if different from patient)

Subscriber Date of Birth

Relationship to Patient

Group #

Policy / Member #

Subscriber SS# or ID

Dental Insurance — Secondary (if applicable)

Insurance Company Name

Phone

Subscriber Name

Group #

Policy / Member #

Assignment & Authorization

I certify that the above information is correct to the best of my knowledge. I authorize the release of any information concerning my health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize and request my insurance company to pay directly to Eastgate Family Dental 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. I authorize the use of my signature on all insurance submissions.

Signature of Patient or Responsible Party

Date