Patient Registration

    General Information

    Your Name (required)

    Your Email (required)

    Preferred Name

    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

    Subscriber's Date of Birth

    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?

    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)

    Hassle-Free Website Management & Support Guaranteed by SimpleWebHelp.com