Patient Registration for Nicollet Station Dental Patient Registration for Nicollet Station Dental Name * How do you wish to be addressed? Date of Birth * Double check your birth year is correct Address * City * State * Zip * Home Phone Number * Cell Phone Number Email Address * Social Security # Mark the appropriate box: * Single Married Divorced Separated Widowed Partnered Account Information Employer Position Work Phone Number Spouse Full Name Spouse Employer Spouse Position Spouse Work Phone Number Insurance Information Primary Dental Insurance Company Name of Policyholder Primary Policyholder's Birth Date ID # Group # Secondary Dental Insurance Company Name of Policyholder Secondary Policyholder's Birth Date ID # Group # Other Information Emergency Contact Name (Someone not living with you.) * Emergency Contact Phone Number * How did you learn about our dental office? (If referred by a friend or relative, please give their name.) I authorize the administration of such medications and performance of such diagnostic and therapeutic procedures as may be necessary for proper dental care. If additional information is needed, I authorize this office to contact the appropriate health care provider or agency to obtain such information. I understand that dental insurance is a contract between the policyholder and the insurance carrier, and that I am responsible for the payment of fees for services not covered in part or in whole by the insurance carrier. I authorize payment of dental insurance benefits directly to this office. The above information is correct to the best of my knowledge. Charges may be assessed if less than 48 hours notice or no notice is given when an appointment cannot be kept. Signature * Clear Today's Date Submit If you are human, leave this field blank.