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    Patient Registration Form PDF

    Uploaded by

    kimmie kinseth

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Registration Form PDF

    Uploaded by

    kimmie kinseth
    28 views1 page

    Original Title

    Patient-Registration-Form.pdf

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    28 views1 page

    Patient Registration Form PDF

    Uploaded by

    kimmie kinseth

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    PLEASE COMPLETE AND BRING TO APPOINTMENT

    COLLEGE OF DENTISTRY
    PATIENT REGISTRATION
    The University of Iowa College of Dentistry and Dental Clinics and the Hospital Dentistry Institute requests this information for the purposes
    of providing a complete and comprehensive evaluation of your dental needs. No persons outside the University will be provided this
    information unless properly authorized by you or required by law. Failure to provide the requested information will limit our ability to assess
    your needs and may result in the College being unable to accept you as a patient.
    PATIENT DATA
    Mr Mrs Rev Print full legal name: last first middle
    Ms Miss Dr
    Female Male Date of Birth: (Month/Day/Year) Social Security # (last 4 only) : Chosen Name:
    Transgender
    Mailing Address: Apt. # PO Box #

    City: State: Zip Code: Email:

    Home Phone # (with area code) Work Phone # (with area code and ext.) Mobile/Other Phone # (with area code)

    Preferred Phone Number to Contact Patient: Home Mobile For appointment reminders, Email Only Email and Text
    Work Other contact me by: Email and Phone Phone Only
    Alternate/Permanent Address (If different than above) City: State: Zip Code:

    EMERGENCY CONTACT INFORMATION (Required by law)


    Emergency Contact: last first middle

    Relationship: Home Phone # (with area code) Other Phone # (with area code) Email Address:

    Mailing Address: City: State: Zip Code:

    Same as above Mailing Address BILLING ADDRESS


    Billing Address: City State Zip Code

    Same as Patient RESPONSIBLE PARTY INFORMATION


    Print full legal name: last first middle Relationship to Patient:

    Mailing Address: City: State: Zip Code:

    Home Phone #(with area code) Mobile/Other Phone # (with area code) Date of Birth: Month/Day/Year Email Address:

    INSURANCE/PAYMENT INFORMATION
    Dental Insurance DWP Medicaid (Title XIX) Medical Insurance Agency
    Yes No Yes No Yes No Yes No Yes No
    POLICY POLICY HOLDER INSURANCE
    NAME OF POLICY HOLDER HOLDER ADDRESS Policy ID # INSURANCE CARRIER M/D EMPLOYER NAME
    (IN ORDER OF FILING) BIRTHDATE (IF DIFFERENT THAN NAME (MEDICAL/DENTAL)
    (REQUIRED) PATIENT)

    PATIENT DEMOGRAPHICS
    The following optional information is collected to better track the demographics of our patient population
    Ethnicity: American Indian or Alaska Native Asian White Hispanic Language Preference: English Spanish
    Black or African American Native Hawaiian or Other Pacific Islander Other:
    How did you hear about us?
    College of Dentistry Patient Friend/Family Health Fair/Local Event Internet Phone Book Social Media
    Radio Newspaper TV ad Bus ad Other
    Referring Dr.: City/State:
    03/2017

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