PATIENT REGISTRATION

Name of patient____________________________________________ Date________________

Date of Birth_________________________ Social Security Number_______________________

Address_____________________________________________________________________

Home Phone________________________________ Work Phone________________________

Employer's Name_______________________________________________________________

Employer's Address_____________________________________________________________

Referred By___________________________________________________________________

(If patient is a minor)

Parent's Name________________________________ Parent's SS#_______________________

Name of a friend or relative who can be reached in case of an emergency:

Name_________________________________________ Phone_________________________

Thank you for choosing us as your health care provider. We are committed to providing you with the best
possible care. Please understand that payment of your bill is considered part of your treatment. The
following is a statement of our Financial Policy which we require that you read, agree to and sign prior
to treatment.

REGARDING INSURANCE
For all treatment (excluding exams, x-rays and cleanings), we require a 25% co-payment at the time the
services are rendered. The balance is your responsibility whether your insurance pays or not. We cannot
bill your insurance unless you bring in all insurance information. Your insurance policy is a contract
between you and your insurance company. Not all services are a covered benefit in all contracts. Some
insurance companies arbitrarily select certain services they will not cover.

PATIENT WITHOUT INSURANCE
Payment is expected at the time services are rendered. In cases where extensive treatment is necessary,
we can discuss a payment plan.

MISSED APPOINTMENTS
Unless cancelled at least 24 hours in advance, a missed appointment will be considered a broken
appointment. Patients demonstrating an inability to keep their appointments will no longer be given
appointments. They will be seen on a call-in basis, as our schedule permits.

"I understand and agree that (regardless of my insurance) I am ultimately responsible for the balance of my
account for any professional services rendered. I have read all the information on this sheet."