[Secure Form] Patient Registration Form

Person Responsible For The Account

Person responsible for your account

Spouse

Father

Mother

Self

Responsible Party Name

Responsible party social security number

Responsible Party Date of Birth

Responsible party age

Responsible party telephone number

Responsible party cell phone number

Responsible party email

Responsible party street address

Responsible party city

Responsible party state

Responsible party zip

Responsible party employer

Responsible party business phone

Spouse or Other Guarantor Information

Spouse/Guarantor Name

Spouse/Guarantor Relation

Spouse/Guarantor DOB

Spouse/Guarantor SSN

Spouse/Guarantor Street

Spouse/Guarantor City

Spouse/Guarantor State

Spouse/Guarantor Zip

Spouse/Guarantor Tel

Spouse/Guarantor Employer

Spouse/Guarantor Bus Tel

Insurance Information

Primary Dental Insurance

Primary Dental Insurance Policyholder

Primary Dental Insurance Policyholder Member ID or SSN

Primary Dental Insurance Policyholder DOB

Secondary Dental Insurance

Secondary Dental Insurance Policyholder

Secondary Dental Insurance Policyholder Member ID or SSN

Secondary Dental Insurance Policyholder DOB

Primary Medical Insurance

Primary Medical Insurance Policyholder

Primary Medical Insurance Policyholder Member ID or SSN

Primary Medical Insurance Policyholder DOB

Secondary Medical Insurance

Secondary Medical Insurance Policyholder

Secondary Medical Insurance Policyholder Member ID or SSN

Secondary Medical Insurance Policyholder DOB

In case of emergency, contact

Emergency Contact Name

Emergency Contact Home Phone

Emergency Contact Work Phone

Authorization To Release Information

I request and authorize Greater Columbus Oral Surgery & Dental Implants to release healthcare information, including pre/postop surgical instructions, questions, concerns, and appointments, prescription refills and pick-ups, and financial and billing information, to the following:

Information Release Authorization 1

Information Release Authorization 2

Information Release Authorization 3

Final Notes

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Fees & Payments

We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, coinsurance, or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney's fees, and court costs.

The signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Authorization

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Patient Information

Person Responsible For The Account

Spouse or Other Guarantor Information

Insurance Information

Health History

Have you had or do you currently have any of the following?

Medication

Is there a family history of:

Allergies

In case of emergency, contact

Authorization To Release Information

Final Notes

Fees & Payments

Authorization