New Patient Registration Form

Name *

First

Last

Sex *

Date of Birth *

Age *

Home Address

Address Line 1

City

State

Zip Code

Billing Address *

Same as Home Address
Different

Cell Phone *

Home Phone *

Work Phone

Driver’s license # *

State *

Email *

SS #

Employer/Occupation

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency

Emergency phone #

Spouse's Name

Spouse's Phone

Primary dental insurance

Group #

ID #

Secondary dental insurance

Group #

ID #

Subscriber’s Name

Date of Birth

SS #

Are you a student?

Whom may we thank for referring you?/ How did you hear of our office?

Payment in full or validated insurance coverage along with estimated co-payment is due at the time of service.
As a service to our patients, we will bill your insurance company. If your insurance company fails to pay any outstanding balance, then payment in full is the responsibility of the insured or the person responsible for the account.
Arrangements for payment other than payment in full or insurance must be made prior to appointments. Any payment plan must be accompanied by a completed financial statement and promissory note.
Balances over 60 days past due will be subject to a finance charge of 1.5% per month (18% APR).
There will be a $15.00 charge on each returned check.
We ask that a 48-hour notice be given for any cancellation of appointments so that we may fill in that time with someone else who desires to have treatment.
There will be a $40.00 per hour charge for broken appointments or cancellations without 48 hours’ notice.

Acknowledgment *

I certify that I have read and completed this form to the best of my knowledge and acknowledge all stipulations hereto in.

Signature

Our Office:

Make an Appointment:

We've Moved!

We relocated to a new and modern facility, built with you in mind.

22833 Bothell Everett Hwy Suite 146, Bothell, WA, 98012