Online Patient Registration | Mark J Andrews DDS

New Patient Registration Packet

Please complete all required sections prior to your appointment at Dental Clinic.

1. Patient Demographics & Contact

First Name *

Last Name *

Date of Birth *

Age

Street Address *

City *

State *

Zip Code *

Cell Phone *

Home Phone

Work Phone

Email Address *

Preferred Confirmation Method

Emergency Contact & Phone *

Whom may we thank for referring you?

4. Dental Concerns & Symptoms

Additional Dental Goals or Questions for the Doctor:

5. Acknowledgements, HIPAA & Consent

A. Notice of Privacy Practices (HIPAA)

I have received and reviewed the Notice of Privacy Practices for Dental Clinic. I understand my rights regarding the disclosure of my protected health information.

Printed Legal Name *

Date *

HIPAA Digital Signature*

Sign here using mouse or finger

B. Treatment Consent & Financial Policy

I authorize diagnostic examinations, x-rays, and standard dental treatment as recommended. I accept financial responsibility for all services rendered and agree to cooperate with insurance claim processing.

Printed Legal Name *

Date *

Treatment & Financial Consent Digital Signature*