Patient Registration - Dr Diehl & Dr Payne Family Dental
Last Name
Last Name is a required field
First Name
First Name is a required field
Middle Initial
Invalid Date of Birth. Format MM/dd/yyyy
DOB (MM/DD/YYYY)
Birthdate is a required field
SSN
Gender
Male
Female
Telephone (Mobile)
Telephone (Work)
Telephone (Home)
Address
City
State
Zip
Email
How did you hear about our office?
Subscriber Name
Subscriber ID
Subscriber DOB (MM/DD/YYYY)
Relationship To Subscriber
Self
Spouse
Child
SignifOther
Employer Name
Employer Phone
Insurance Company
Insurance Phone
Insurance Group
Employer Phone
RESPONSIBLE PARTY(if not patient)
First Name
MI
Last
DOB (MM/DD/YYYY)
Gender: Male
Gender: Female
Telephone (Mobile)
Telephone (Work)
Telephone (Home)
Address (if different)
City
State
Zip
Email
Relationship to Patient
EMERGENCY CONTACT
Emergency Contact Name
Relationship
Emergency Phone
Name of Physician
Physician Phone
AUTHORIZATION - I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child’s) health care, advice, and treatment to another dentist, or for evaluating and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to dentist or dental group and understand that my insurance benefits may pay less than the actual bill for services and that I am responsible for any services not paid or covered by my insurance benefits and any account balance.
ELECTRONIC COMMUNICATIONS - I consent to receiving HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment and health care operations. I understand that there is no obligation to receive these electronic communications. Message/data rates may apply, and I may opt-out of receiving electronic communications at any time by clicking the unsubscribe link provided in emails, or by replying STOP via text. I attest to the accuracy of the information on this page.