Patient Registration - Single Form Only - Santa Cruz Pacific Dental

Appointment Status
- If this appointment is for your child, please check the box.
- If your child's last name and/or address are not the same as yours, please check this box
Patient Information
Patient Name*
First Last
Middle Name*
Preferred to be called by
Address*
Street Address City State ZIP Code
Home Phone*
FAX
Cell
Email*
Age*
Gender*
Marital Status*
School*
Grade*
Parent's Info
Parent Name*
First Last
Parent Phone No.*
Email*
Parent Address*
Street Address City State ZIP Code
Birthdate*
MM slash DD slash YYYY
Age
Gender*
Marital Status*
Primary Dental Insurance Carrier
Insurance Company
Group No.
Employer Name
Insured's Name
Date of Birth
MM slash DD slash YYYY
Relationship to Patient
Insured's I.D. No.
Secondary Dental Insurance Carrier
Insurance Company
Group No.
Employer Name
Insured's Name
Date of Birth
MM slash DD slash YYYY
Relationship to Patient
Insured's I.D. No.
Getting To Know You
Is another member of your family or relative a patient at our office?

Name
Relationship
You were referred to us by:

Name
Emergency Contact
Name*
First Last
Cell Phone*
Home Phone
Address
Street Address City State ZIP Code
Account Information
Personal Financially Responsible For Account
First Last
Relationship to Patient
Address
Street Address Address Line 2 City State ZIP Code
Phone
Your Account Information
Name
First Last
Occupation
Employer's Name
Address
City
Phone
FAX No.
Your Spouse's Account Information
Name
First Last
Occupation
Employer's Name
Address
City
Phone
FAX No.
Consent For Treatment
1. 1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient dental needs.
2. 2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3. 3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. 4. I give consent to the doctor's or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
5. 5. I agree to be responsible for payment of all services rendered on my behalf or my depends. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
Patient's Signature*
Date*
MM slash DD slash YYYY
Parent/Responsible Party's Signature*
Relationship to Parent*
Click to View the Privacy Policy Click to View the Financial Policy
- I have read and acknowledged the Privacy Policy & Financial Policy agreements. These statements can be found in the links below.
Click to View the Privacy Policy
Click to View the Financial Policy

Patient Information

Parent's Info

Primary Dental Insurance Carrier

Secondary Dental Insurance Carrier

Getting To Know You

Emergency Contact

Account Information

Your Account Information

Your Spouse's Account Information

Consent For Treatment