Patient Registration Form

Patient Last Name(*)
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First Name(*)
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Middle
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Address1:(*)
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Address 2:(*)
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City(*)
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State(*)
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Zip(*)
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Home Phone(*)
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Sex
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Birthdate(*)
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Marital Status(*)
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Occupation(*)
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Employer(*)
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Employer Address(*)
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Employer Phone(*)
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Spouse's Name(*)
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Spouse's Birthdate(*)
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Spouse's Occupation(*)
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Spouse's Employer(*)
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Who Referred You?(*)
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Step 2 of 6

Primary Dental Insurance

Who is Responsible for this Account?(*)
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Primary's Employer Name(*)
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Relationship to Patient(*)
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Insurance Company(*)
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Group #:(*)
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Is Patient Covered by Additional Insurance?(*)
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Subscriber's Name(*)
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Subscriber's Birthdate(*)
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Secondary Dental Insurance

Relationship to Patient:
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Insurance Company:
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Group #:
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Is patient covered by additional insurance?
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Subscriber's Name:
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Birthdate:
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Primary Medical Insurance

Primary's Employer Name:
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Relationship to Patient:
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Insurance Company:
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Group #:
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Is patient covered by additional insurance?
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Subscriber's Name:
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Birthdate:
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Secondary Medical Insurance

Relationship to Patient:
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Insurance Company:
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Group #:
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Is patient covered by additional insurance?
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Subscriber's Name:
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Birthdate:
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Home Phone(*)
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Work Phone(*)
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Spouse's Work Phone
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Best Time/Place to Reach You
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IN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household)

Emergency Contact Name(*)
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Home Phone(*)
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Work Phone(*)
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Relationship(*)
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Reason for Your Visit to Dr. Roberson
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Dentist
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City/State
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Date of Last Dental Visit
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Date of Last Dental X-Rays
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Please indicate if you have had any of the following (check all that apply)

Dental History(*)

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Physician Name
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Date of Last Visit
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Please indicate if you have had any of the following. By placing a check in the box you are stating YES to the associated item. By NOT placing a check in the box, you are stating NO to the associated item.

Health History

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List All Medications You are Currently Taking
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Pharmacy Name
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Phone
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Allergies

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I certify by submitting this online form that I (or my dependent) have insurance coverage with above mentioned company and assign directly to Dr. John B. Roberson, DMD of the Oral & Facial Surgery Center, PA all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this form on all insurance submissions. By submitting this form, you are stating that all information to your knowledge is correct, and are authorizing Dr. John B. Roberson of The Oral & Facial Surgery Center, PA of Hattiesburg, Mississippi to use this information in handling your appointment and any future visits. Updates will be attached to your original patient information form at future appointments with Dr. Roberson.

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