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  Patient Registration


4175 S.W. 64th Avenue
Davie, FL 33314
Phone: 954-792-3800
Barry Bluth, DMD, Sherri Bluth, DMD, Norman Bluth, DDS

info@bluthfamilydental.com

First Name
Last Name
Patient is
 Policy Holder
Responsible Party
Responsible Party
(if someone other than the patient)
First Name
Last Name
Address 1
Address 2
City, State, Zip
Pager
Home Phone
Work Phone
Ext
Cellular
Soc. Sec
Drivers Lic
Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information
Address 1
Address 2
City
State, Zip
Pager
Home Phone
Work Phone
Ext
Cellular
Sex
 Male
Female
Marital Status
 Married
Single
Divorced
Separated
Widowed
Birth Date
Age
Soc. Sec
Drivers Lic
E-mail
  I would like to receive
correspondences via e-mail.
Section 2
Employment Status
 Full Time
Part Time
Retired
Student Status
 Full Time
Part Time
Pref. Dentist
Section 3
Emergency Contact
Emergency #
Physician's Name
Physician's #
Pharmacy Name
Pharmacy
Cell phone
Primary Insurance Information
Name of Insured
Relationship to Patient
Self
Spouse
Child
Other
Insured Soc. Sec
Insured Birth Date
Employer
Address
City,State,Zip
Ins. Company
Address
City,State,Zip
Secondary Insurance Information
Name of Insured
Relationship to Patient
Self
Spouse
Child
Other
Insured Soc. Sec
Insured Birth Date
Employer
Address
City,State,Zip
Ins. Company
Address
City,State,Zip
Rem. Benefits
.00
Rem. Deduct
 .00
CONSENT FOR TREATMENT / INSURANCE
ASSIGNMENT/FINANCIAL RESPONSIBILITY

1) The patient or his representative recognizing the need for care, consents to all services as ordered by our office, including medical treatment and examination, laboratory and x-ray procedures, minor or emergency surgical treatment, or other treatment rendered under specific instructions of the doctor.

2) I hereby authorize Bluth Family Dental to furnish information to insurance carriers concerning my dental needs and treatment and I hereby assign to Bluth Family Dental all payments for services rendered to my dependants or myself.

3) I understand that I am financially responsible for any and all unpaid amounts incurred in treatment.

4) I also understand that if my account remains unpaid and is forwarded to a collection agency I will be responsible for any reasonable collection costs, including reasonable attorney fees.

5) I understand that a minimum 24 hours notice is required for cancellation of appointments. A broken appointment fee may be charged to my account, and is payable by me if 24 hrs. notice is not given.

 

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