Camellia Periodontics

Online Patient Registration
Patient
Last Name
First Name
Middle Initial
Street, Apt #, or P.O. Box
City
State
Zip Code
E-Mail
Daytime Phone (916-555-1212)
Work Phone (916-555-1212)
Best Time to Call
Martial Status	SingleMarriedDivorced
Date of Birth (mm/dd/yy)
Sex	Female Male
Employer Name (Note: Employment information is needed only if you have a dental benefit through your employer)
Employer Address
Employer's Phone (916-555-1212)

Spouse
Last Name
First Name
Middle Initial
Work Phone (916-555-1212)
Date of Birth (mm/dd/yy)
Spouse's Employer Name
Employer Address

Dental Benefit Information
Parent or Guardian's name if patient is a minor
Who may we thank for your referral?

Primary Dental Plan Information
Primary Plan Carrier
Insured's Name
Insured's date of birth (mm/dd/yyyy)
Relationship to patient
Policy #
Group #
Dental plan address
Phone (800-555-1212)
Do you have dual coverage?	Yes No
IF YES, PLEASE COMPLETE THE FOLLOWING SECONDARY PLAN INFORMATION

Secondary Dental Plan Information
Insured's Name
Insured's date of birth (mm/dd/yyyy)
Relationship to patient
Name of dental plan
Policy #
Group #
Dental plan address
Phone (800-555-1212)
Employer Name
Employer Address
Employer's Phone (916-555-1212)