Derek Renfroe DMD, FICOI, FAGD

311 Spring Street, Dover, TN 37058

931 232 7105

Patient Registration

Welcome! Please complete the following confidential information to help us better serve you.

Section 1: Patient Information:

Patient:

Address:

City/ State/ Zip:

Telephone (Home)

(Work)

(Cell)

Email:

Employer/ School:

Date of Birth:

Social Security Number

Do you have dental insurance?

Yes No

If yes, proceed to the next section. If no, skip the next section

Section 2: Dental Insurance Information:

Is the dental insurance in your name?

Yes No

If yes, Insurance Company

ID#

Group #

If No, Insured's Name

Date of Birth

Employer

Insurance Company

ID#

Group #

Secondary Coverage?

If No, Insured's Name

Date of Birth

Employer

Insurance Company

Section 3: Account Information:

(If different than the patient, please complete)

Send Bill To:

Name:

Address:

City/ State/ Zip:

Telephone (Home)

(Work)

(Cell)

Employer/ School:

Date of Birth:

Social Security Number

In case of emergency, whom should we contact?

Telephone:

Relationship:

Who may we thank for your referral?

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date: