Bello-Burgos Smiles Update Patient Registration Doral Form

UPDATE TO REGISTRATION AND MEDICAL HISTORY
To assist us in serving you, please complete the following confidential form. The information provided is important to your dental health.

Hello. In order to keep our records updated for 2022, we would appreciate your cooperation in completing this brief form.
Thank you for your understanding.

Patient Information

Patient Name:

Birth Date:

Address:

City:

State:

Zip:

Home #:

Work #:

Mobile #:

Email:

Insurance Information

Do you have new insurance for the 2022 year?:

Yes

If Yes, please fill out the section below and inform our front desk with your insurance card to update and expedite your visit.

Insurance Company:

Insured Name (If not patient):

Insured Relationship to Patient:

Insured Birth Date:

Group #:

Member ID#:

By signing below, I authorize the release of any dental or other information necessary to process my claims.
I also authorize payment of dental benefits to be made to Bello-Burgos Smiles.

Signature (Parent/Guardian):

Date:

I certify and understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered these questions truthfully to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication. For this, I will not hold my dentist, or any other member of their staff responsible for any errors or omissions that I may have made in the completion of this form.