Patient Registration Form – Medical Circle

Registration Date

Patient ID

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)

Date

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

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

Date

If signed by guardian/representative

Name

Relationship to Patient

Representative Signature

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.

Teledentistry Patient Registration Form

1. Personal Information

2. Contact Information

3. Emergency Contact Information

4. Insurance Information

Insurance Authorization

5. Referral Information

6. Appointment & Communication Preferences

7. Technology Information

8. Financial Information

9. Legal Guardian Information (if patient is minor)

Second Guardian/Parent

Custody Information

10. Marketing & Communication Consent

11. Authorization & Signature

If signed by guardian/representative

12. Office Use Only

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