Patient Registration

Patient Registration Please complete one form per family, as long as information is the same for all family members. Thank you!

Street Address*

Zip Code *

Home Telephone

Child #1 Name (first and last)*

Child #1 Date of Birth*

Child #2 Name (first and last)

Child #2 Date of Birth

Child #3 Name (first and last)

Child #3 Date of Birth

Child #4 Name (first and last)

Child #4 Date of Birth

Parent #1 Name (first and last)*

Parent #1 Date of Birth*

Parent #1 Cell Phone*

Parent #1 Email Address*

Parent #1 Address (ONLY if different than above)

Parent #2 Name (first and last)*

Parent #2 Date of Birth*

Parent #2 Cell Phone*

Parent #2 Email Address*

Parent #2 Address (ONLY if different than above)

How would you prefer that we contact you ?*

PhoneEmailText

Referred by? (Insurance, Yelp, Google, Pediatrician, Existing Patient -Please Enter Name)*

Insurance Information

Select your dental insurance from the drop-down list (*if NO INSURANCE, select No Insurance)*

Please select the state that your insurance is billed through (review the address provided with your insurance benefits or located on the back of the card).*

If you cannot locate your dental insurance from the list above, please enter here. (If not applicable, enter N/A) *

If your child has Kaiser Permanente Insurance, please enter Medical Record Number (If not applicable, enter N/A) *

Enrollee/Subscriber Name (please make sure we have the date of birth above to properly submit your claim--thank you)*

Primary Insurance Subscriber/ Enrollee ID or SS# - *This is REQUIRED in order to bill your insurance* (if no dental insurance, enter N/A)*

Name of Secondary Insurance (if applicable)

If you cannot locate your dental insurance from the list above, please enter here. (If not applicable, enter N/A)

Secondary Insurance Subscriber/Enrollee Name (please make sure we have the date of birth above to properly submit your claim --thank you)

Secondary Insurance Subscriber ID or SS# *This is REQUIRED in order to bill your insurance*

Name of Person responsible for the account:

We will do our absolute best to run on time! We respect your time. We ask that you please give us 24 hours notice if you are unable to make your scheduled appointment. Thank you.

I authorize Dr. Harmer & her associates to perform the necessary dental treatment my child may need for his or her well-being. I authorize Dr. Harmer & her associates to release any information, including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payers (i.e. insurance company) and/or health practitioners (i.e. you child's physician or orthodontist).

I request that my insurance company pay directly to Dr. Harmer & any associates, and I understand that my insurance carrier may pay less than the actual bill for service; therefore, I agree to be responsible for the payment of all services rendered on my child's behalf. I authorize the use of this signature on all my insurance submissions.

Parent/Legal Guardian Name

Signature*

Clear

Date