Patient Registration

General Information

Your Name (required)

Your Email (required)

Preferred Name

Date of Birth

Home #

Cell #

City: State: Zip:



Work #


Spouse's Name

Date of Birth


Work #


If patient is a child:

Father's Name


Work #

Mother's Name


Work #

Dental Insurance

Insurance Company

Subscriber's Name

Subscriber's Date of Birth

ID #

Group #


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


Whom may we thank for this referral?

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.

Signature: Please Sign Below

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

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