Patient Registration - Legacy Dental Franklin

ID:

Chart ID:

First Name

Last Name

Middle Initial:

Patient Is:

Policy Holder
Responsible Party

Preferred Name:

Responsible Party (if someone other than the patient)

First Name

Last Name

Middle Initial:

Address:

Address 2:

City, State, Zip:

Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Birth Date:

Soc Sec:

Drivers Lic:

Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder

Patient Information

Address:

Address 2:

City:

State/Zip:

Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Birth Date:

Age:

Soc Sec:

Drivers Lic:

Email:

I would like to receive correspondences via email.

Soc. First Cellular:

Primary Insurance Information

Name of Insured:

Relationship to Insured:

Self
Spouse
Child
Other

Insured Soc. Sec:

Insured Birth Date:

Employer:

Ins. Company:

Emp. Address:

Ins. Company Address:

Emp. Address 2:

Ins. Company Address 2:

Emp. City, State, Zip:

Ins. Company City, State, Zip:

Rem. Benefits:

Rem. Deduct:

Secondary Insurance Information