New Patient Registration Form

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.
The undersigned hereby authorizes doctor to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patients’ s dental needs.
I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk, Furthermore, I authorize and consent that doctor choose and employ such
assistance as deemed fit to provide recommended treatment.
I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1% finance charge maybe added to my account, in addition to any collection charges.
I understand that where appropriate, credit bureau reports may be obtained.
I understand that it is my responsibility to advise your office of any changes in the information obtained on this form.
I authorize the use of my social security number to file my dental claim.

Patient Registration