Patient Registration Form Your Smile Partners PLLC — Teledentistry Patient Registration Form Teledentistry Patient Registration Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555-SMILE Print Form Save PDF to Device Submit & Upload to Dropbox Clear All Fields Registration Date Patient ID 1. Personal Information Full Legal Name Preferred Name Social Security Number Format: 123-45-6789 Date of Birth Age Gender Male Female Non-binary Prefer not to disclose Other Marital Status Single Married Divorced Widowed Domestic Partner Language Preference English Spanish Other Occupation Employer Work Phone Extension 2. Contact Information Primary Address Street City State ZIP How long at this address? Years Months Mailing Address (if different) Street City State ZIP Phone Numbers Home May we leave messages? Cell May we text? Work May we call at work? Email Address Appointment reminders via email Preferred method of contact Phone Text Email Best time to contact Morning Afternoon Evening Anytime 3. Emergency Contact Information Primary Emergency Contact Name Relationship Phone Alternate Address Secondary Emergency Contact Name Relationship Phone Alternate 4. Insurance Information Primary Dental Insurance Insurance Company Phone Number Policy/Member ID Group Number Subscriber Name Subscriber DOB Relationship to Subscriber Self Spouse Child Other Subscriber Employer Employer Address Secondary Dental Insurance (if applicable) Insurance Company Phone Number Policy/Member ID Group Number Subscriber Name Medical Insurance Insurance Company Policy/Member ID Group Number Insurance Authorization File insurance claims on my behalf Accept assignment of benefits Release necessary information to process claims Signature (Insurance Authorization) Clear Date 5. Referral Information Internet search Google reviews Social media Insurance directory Friend/family referral Healthcare provider referral Advertisement Previous patient Other If Other Referring person/practice name May we thank them for the referral? 6. Appointment & Communication Preferences Preferred appointment times Early morning (7-9 AM) Morning (9-11 AM) Midday (11 AM-1 PM) Afternoon (1-4 PM) Late afternoon (4-6 PM) Evening (6-8 PM) Preferred days Monday Tuesday Wednesday Thursday Friday Saturday Teledentistry platform preferences Zoom Doxy.me Microsoft Teams FaceTime No preference Reminder preferences Phone call Text message Email No reminders 24 hours 48 hours 1 week 7. Technology Information Primary device iPhone Android phone iPad Android tablet Windows laptop/desktop Mac laptop/desktop Chromebook Internet connection High-speed WiFi Mobile data DSL/Cable Fiber optic Camera quality HD (1080p) 4K Standard Unsure Environment I have a quiet, private space I do not have a private space I need technical assistance I do not need assistance 8. Financial Information Employment Status Full-time Part-time Self-employed Retired Student Unemployed Payment responsibility Self Parent/guardian Spouse Insurance only Preferred payment method Cash Check Credit card Debit card HSA/FSA Payment plan Credit card information (for deposits/copays) Card Type Visa MasterCard American Express Discover Number Expiration (MM/YY) Name on Card Billing ZIP CVV 9. Legal Guardian Information (if patient is minor) Guardian Name Relationship Date of Birth SSN Employer Work Phone Second Guardian/Parent Name Relationship Phone Custody Information Both parents have equal rights Sole custody (specify) Court order on file 10. Marketing & Communication Consent Appointment reminders Treatment follow-up communications Oral health education materials Practice newsletters Promotional offers Birthday/holiday greetings Patient satisfaction surveys Preferred communication method for marketing Email Text message Phone call Mail None 11. Authorization & Signature I certify that the information provided is true and complete. I am financially responsible for all services provided, and payment is due at time of service unless arranged otherwise. I will provide 24-hour notice for cancellations; a fee may apply for missed appointments. I authorize Your Smile Partners PLLC to perform necessary teledentistry services. I agree to the Authorization statements above. Patient Signature Clear Date If signed by guardian/representative Name Relationship to Patient Representative Signature Clear Date 12. Office Use Only Registration completed by Date processed Time Insurance verified Date Technology test completed Tech test date Welcome packet sent Method First appointment date Time Provider assigned Notes Thank you for choosing Your Smile Partners PLLC for your teledentistry needs. We look forward to providing you with exceptional virtual dental care. If you have any questions, please contact us at talk@yoursmilepartners.com. Ready
