Patient Registration Form Patient Intake Form (#1)Patient First Name Patient Middle Initial Patient Last Name Prefered Name / Nickname Patient Address Patient City Patient State Patient Zip Code Patient Phone Number Patient Birthdate Patient Gender - Select -MaleFemaleOthersPatient Email I would like to receive emails YesAre you registering yourself or someone else? Myself Someone ElseAre you financial responsible for the visit (if you are primary policy holder for insurance, choose yes)? Yes NoResponsible Party First Name Responsible Party Last Name Responsible Party Address Responsible Party City Responsible Party State Responsible Party Zip Code Responsible Party Phone Number Is the responsible party the policy holder for the patient? Yes NoPolicy Holder Status Primary Policy Holder Secondary Policy HolderDo you have insurance? Yes NoFirst Name of Insured Last Name of Insured Employer ID Carrier ID Insured Social Security Number Insured Birthdate Relationship to Insured Self Spouse Child OtherEmployer Employer Address Line 1 Employer City Employer State Employer Zip Code Please indicate primary insurance Insurance Address Insurance City Insurance State Insurance Zip Code I authorize Deadwood Dental to submit to my insurance, and give permission to call or send a text message to my cell phone concerning payments, dental benefits, marketing, and financial agreements.Submit Form Back to patient forms
