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New Patient Form

Home » Patient Resources » New Patient Form

New Patient Request Form

Please do not include personal health information or symptoms. This form should only be used for general inquiries or appointment requests.

DATE:

TITLE: Mr.Mrs.Ms.Dr.

SEX: MaleFemale

FIRST NAME:

MI:

LAST NAME:

NICKNAME:

EMAIL:

ADDRESS:

CITY:

STATE:

ZIPCODE:

HOME PHONE:

CELL PHONE:

OCCUPATION:

MARITAL STATUS: SingleMarriedDivorcedWidowLegally Separated

EMPLOYMENT STATUS: Not EmployedFull TimePart TimeRetired

EMPLOYER:

BUSINESS PHONE:

PERSONAL PAYMENT TYPE: CashCheckCredit Card

DENTAL INFORMATION

WHAT TYPE OF APPOINTMENT WOULD YOU LIKE TO REQUEST?

WHAT SERVICES ARE YOU INTERESTED IN?

HAVE YOU EVER BEEN A PATIENT OF OUR PRACTICE? YesNo

WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?

FORM COMPLETION

I certify that I have read and I understand the questions above. I will not hold the doctors of ReGen Endodontics or any other member of their staff, responsible for any errors or omissions that I have made in the completion of this form.

FEES AND PAYMENTS

All fees are due upon completion of treatment. I hereby authorize payment to ReGen Endodontics of the benefits otherwise payable to me. 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, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to ReGen Endodontics of the benefits otherwise payable to me.

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.

By completing this form, you are giving us permission to follow-up by phone, email or text.