Dental Philosophy - Laguna Hills Dental.com

Patient Registration
Note: Please complete all information as it applies to you. The areas marked with the asterisk (*) are necessary.
After you click the Submit button below, you will be taken to the Medical History Form which must also be completed.
Thanks in advance..

First Name: Last Name:

E-mail address*:

Patient is: Policy Holder Responsible Party

Responsible Party (if someone other than patient):
First Name: Last Name:
Address: Address2:
City, State ZIP:
Home Phone: Work Phone: Ext:
Cellular: Pager:
Birth Date*: Soc. Sec. number:*
Drivers Lic.*:
Responsible party is also a Policy Holder Primary Insurance Policy Holder
Secondary Insurance Policy Holder

Patient Information:

Address:
Address2:
City, State ZIP:
Home Phone: Work Phone: Ext:
Cellular: Pager:
Birth Date*: Soc. Sec. number*:
Drivers Lic.*:
Sex: Marital Status:
I would like to receive correspondences via e-mail.

SECTION 2

Employment Status: Student Status:
Medicaid ID:
Preferred Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
Pref. Hyg.:

SECTION 3

Drivers Lic.:
Pager Number:
Cellular Number:
Who Referred you?

Primary Insurance Information:

Name of Insured: Relationship to Patient:
Social Security Number: Insured Birth Date:

Employer:
Address:
Address2:
City, State ZIP
Rem. Benefits:
Rem. Deduct:

Insurance Company:
Address:
Address2:
City, State ZIP:

Secondary Insurance Information

Name of Insured: Relationship to Patient:
Social Security Number: Insured Birth Date:

Employer:
Address:
Address2:
City, State ZIP
Rem. Benefits:
Rem. Deduct:

Insurance Company:
Address:
Address2:
City, State ZIP: