Patient Registration





General Information

Your Name (required)

Your Email (required)

Nickname

Date of Birth

Home #

Cell #

Address
City: State: Zip:

Employer

Employer

Work #

Spouse

Spouse's Name

Date of Birth

Employer

Work #

Children

If patient is a child:

Father's Name

Employer

Work #

Mother's Name

Employer

Work #

Dental Insurance

Insurance Company

Subscriber's Name

ID #

Group #

Emergency

Name and Phone # of 2 persons whom we may contact in case of emergency

Name of previous dentist where records could be obtained, if necessary

Referral

Whom may we thank for this referral?

Verification: Enter These Characters Below
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Our Payment Policy

PAYMENT IS DUE AS SERVICES ARE RENDERED. We will gladly file your insurance claim for you. A service charge of .66% per month (7.92% annually) will be automatically added to any balance over 60 days. A $25.00 fee will be charged on all returned checks.

I understand that responsibility for payment for dental services provided in this office for myself, or my dependents, is mine, due and payable at the time services are rendered unless financial arrangements have been made. If insured, I authorize any insurance payment to go directly to Dr. Robert Derr.

(After you click Submit, please make sure you complete both forms)