Patient Registration Form

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Release

  • I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.

    I authorize release of any information concerning my health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

    I authorize release of any information concerning my health care, advice and treatment to another dentist.

    I understand that FastNewSmile® is not a contracted provider with my insurance carrier. My dental insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor.

    I attest to the accuracy of the information on this page.

  • Date Format: MM slash DD slash YYYY