Patient Registration Form Patient Details

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  •  Yes
  •  No

Patient Registration Form Contact Information

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  •  GOOGLE
  •  OTHER

Patient Registration Form Responsible Party's Information

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  •  Yes
  •  No
  •  Yes
  •  No

Patient Registration Form Employer

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Patient Registration Form Primary Insurance Details

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Patient Registration Form Secondary Insurance

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Patient Registration Form Emergency Contact Information

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Patient Registration Form Authorization

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The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dental office. I understand that I am financially responsible for any balance. I also authorize Designing Smiles LLC or insurance company to release any information required to process my claims.

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