Alan Golshanara DDS

6600 Mercy Court, Suite 220
Fair Oaks, CA 95628
(916) 965-7036

Patient Registration

Patient Registration Form

Patient Information

Is the patient a minor?

YesNo

First Name

Last Name

Nickname

Gender

Date of Birth

Age

Race

Interests

Address

City

State

Zip Code

Home Phone

Cell Phone

School/Employer

Grade/Position

Work Phone

Referral Source

Family Information

Reason for Visit

Previous Dentist

Last Cleaning Date

Primary Responsible Party

First Name

Last Name

Date of Birth

Social Security #

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Employer

Other Information

Insurance Information

Insurance Company

Insurance Phone

Member ID

Secondary Responsible Party

First Name

Last Name

Date of Birth

Social Security #

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Employer

Other Information

Insurance Information

Insurance Company

Insurance Phone

Member ID

Oral Habits

Cheek Biting

Teeth Clenching

Nail Biting

Thumb Sucking

Consent & Authorization

Relationship to Patient

If other than parent, specify

Consent Name

Consent Date

I hereby authorize the dental staff to perform necessary dental services for the patient. I understand that I am financially responsible for all services rendered.

Alan Golshanara DDS

Patient Registration Form

Patient Information

Primary Responsible Party

Insurance Information

Secondary Responsible Party

Insurance Information

Sleep & Breathing Assessment

Health History

Oral Habits

Additional Health Questions

Consent & Authorization