New Patient Registration - English Rows Dental Group

New Patient Registration Form

At English Rows Dental Group, we are pleased to offer New Patients the ability to fill out their initial intake form online.

Personal Information
Please take a moment to fill out your personal information in this section of the form.
Patient's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Parent/Guardian Name
First Last
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Cell Phone
Business Phone
Email
Enter Email Confirm Email
Smile Reminder
Please check here so we will place you in our Smile Reminder system which will provide you with email and text message reminders of upcoming appointments.
- Smile Reminder Notification
Guarantor Name*
First Last
Drivers License Number
Other Family Members
Patient Last 4 SSN*
We will collect the entire SSN when you arrive for your visit
Spouse/Parent Last 4 SSN
We will collect the entire SSN when you arrive for your visit

Primary Insurance Coverage
Please provide us with your primary insurance information.
Do you have Dental Insurance?*
- Yes
- No
Do you have a Secondary Dental Insurance Policy?*
- Yes
- No
Employee Name*
First Last
Employee Date of Birth*
MM slash DD slash YYYY
Employer Name*
Years Employed
Primary Insurance Company*
Primary Insurance Company Phone
Primary Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Primary Insurance Policy Number
Employee Last 4 SSN*
Union Local or Group
Secondary Insurance Coverage
Please provide us with your secondary insurance information.
Employee Name
First Last
Date of Birth
MM slash DD slash YYYY
Employer Name
Years Employed
Secondary Insurance Company
Secondary Insurance Phone
Secondary Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Insurance Policy Number
Employee Last 4 SSN
Union Local or Group

Dental History
Purpose of Initial Visit*
Are there any concerns you would like addressed?
Is there anything that you would change with your teeth?
Would you be interested in an esthetic evaluation with before and after simulations?
- Yes
- No
Previous dental experience
When was your last professional dental cleaning?
MM slash DD slash YYYY
When was your last dental visit?
MM slash DD slash YYYY
What was done?
Dentist Name
(If known)
First Last
Dentist's Address
Street Address Address Line 2 City State ZIP Code
Have you made regular dental visits in the past?*
- Yes
- No
How often?
Were x-rays taken?
- Yes
- No
Have you had any complications with dental treatment in the past?
- Yes
- No
Please explain:

Certification and Acknowledgement
By submitting this online form you are acknowledging all of your answers to be true and accurate. You are also acknowledging that you are in agreement with the English Rows Dental Group Privacy Policy and HIPAA guidelines. You are also providing your agreement to the following statements: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment. I consent to the disclosure of my records (or my child's records) to the following persons who are involved in my care (or my child's care) or payment for that care. My consent to disclosure of records shall be effective until I revoke it in writing. I authorize payment directly to the dentist or dental group or insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full on all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, by my dental care payor. Please type your name and indicate today's date as your acknowledgement below.
Name
First Last
Date
MM slash DD slash YYYY

Laura H
Patient