Antalis - Patient Registration

Please complete all of questions to the best of your ability. The better we communicate, the better we can care for you. Questions are welcome and appreciated.

About You

Patient First Name*

Patient Middle Name

Patient Last Name*

Nickname

Date of Birth*

Age

SSN

Gender*

Male
Female

Home Phone*

Work Phone

Cell Phone

Driver Lic.

Patient Email*

Preferred way to contact*

Home phone
Work phone
Cell phone
Email

Patient Marital Status

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Employer Name

Employer Address

How long there?

Occupation

When & where are the best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

Previous/Present Dentist

Last Visit Date

Spouse Information

Spouse Name

Spouse Employer

Work Phone

SSN

Driver Lic.

Date of Birth

Person Responsible for Account*

Billing Address

Work Phone

Home Phone

Relationship

Employer

SSN

Driver Lic.

Primary Insurance

Dental Coverage?*

Yes
No

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone

Group or Policy #

Insured's Name

Relation

Insured's Birth Date

Insured's ID

Insured's Employer

Employer's Address

Secondary Insurance

Dental Coverage?*

Yes
No

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone

Group or Policy #

Insured's Name

Relation

Insured's Birth Date

Insured's ID

Insured's Employer

Employer's Address

Please, bring insurance card(s) for dental coverage to your visit.

Neighbor or Relative Not Living With You (For Emergency)

Name

Relation

Work Phone

Home Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Comments

This field is for validation purposes and should be left unchanged.