Alan Golshanara DDS

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

Patient Registration

Dental Registration Form

Step 1 of 6

Patient Info

Insurance

Contact

Dental History

Health

Final

Patient Information

Date *

SS/HIC/Patient ID #

Last Name *

First Name *

Middle Initial

Address *

City *

State *

Zip Code *

Email Address

Birthdate *

Sex *

MaleFemale

Age

Marital Status

Address *

Insurance Information

Who is responsible for this account? *

Relationship to Patient *

Primary Insurance

Insurance Company

Group #

Is patient covered by additional insurance?

YesNo

Subscriber's Name

Subscriber's Birthdate

Subscriber's Social Security #

Relationship to Patient

Contact Information

Home Phone

Work Phone

Extension

Cell Phone

Spouse's Work Phone

Best time and place to reach you

Emergency Contact

Specify someone who does not live in your household

Emergency Contact Name *

Relationship *

Home Phone

Work Phone

Final Steps

Has there been any change in your health since your last dental appointment?

YesNo

For what conditions?

Are you taking any new medications?

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Dr. Alan Golshanara 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.

Patient's Signature *