Registration - NC Prosthodontic Specialists

Before your first visit, complete this form online
or, if you prefer, download and fill out our Patient PDF forms.

Also for your first visit, please bring: Doctor’s Referral Form, Relevant X-rays (if available), List of Medications, List of Medical Conditions, Dental or Medical Insurance Card

New Patient Registration

Step 1 of 4

First name

Last Name

Gender

Male

Female

Marital Status

Married

Single

Minor (under 18 years)

Social Security #

Birth Date

Cell Phone

Home/Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer

Employer Name

Occupation

Emergency Contact

Contact name

Emergency Contact Phone

Relationship to Patient

Visit

What is the reason for your visit?

Whom may we thank for referring you?

Responsible Party

Is Patient the Responsible Party?

“Responsible Party” is the person financially responsible for the care provided to the patient.

Yes

No, someone else

Responsible Party Name

First Last

Responsible Party Social Security #

Responsible Party Birthdate

Responsible Party Phone

Responsible Party Address

Street Address City State / Province / Region ZIP / Postal Code

Insurance

Is Patient the Primary Insurance Holder

Yes

No, someone else

Insured Name

Relationship to Patient

Insured Social Security #

Insured Birthdate

Insured Phone

Insured Employer

Insured Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Insurance

Insurance Company

Group #

Insurance Phone

Insurance Company Address

Street Address City State / Province / Region ZIP / Postal Code

Do you have Secondary Insurance?

Yes

Secondary Insurance

Secondary Insurance Company

Secondary Insurance Group #

Secondary Insurance Phone

Secondary Insurance Address

Street Address City State / Province / Region ZIP / Postal Code

Signature

Type your full name

If this form was NOT completed by the patient, what is your relationship?

New Patient Registration

Employer

Emergency Contact

Visit

Responsible Party

Insurance

Primary Insurance

Secondary Insurance

Medical History

Signature