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?

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?
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: