Patient Registration - Dr Diehl & Dr Payne Family Dental
How did you hear about our office?
Subscriber DOB (MM/DD/YYYY)
Relationship To Subscriber
RESPONSIBLE PARTY(if not patient)
Address (if different)
Relationship to Patient
Emergency Contact Name
Name of Physician
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.