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 #

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 *

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