Form

Patient Registration

Welcome to Kai Family Dentistry! Thank you for taking the time to complete your patient registration.
We look forward to taking care of you!

Patient Information

First Name

Last Name

Middle Initial

Preferred Name

Patient Is

Address

City

Zip Code

Home Phone

Work Phone

Mobile Phone

Sex

Marital Status

Date Of Birth

SSN

Drivers Licence #

Employment Status

Student Status

Name of School

Opt Out

Responsible Party

Individual Financially Responsible for Patient

First Name

Last Name

Address

City

Zip Code

Home Phone

Work Phone

Mobile Phone

Date Of Birth

SSN

Drivers Licence #

Opt Out

Primary Insurance Information

Name of Insured

Relationship to Insured

Insured SSN or Insurance ID#

Insured Date Of Birth

Employer Name and Address

Address

City

Zip Code

Insurance Company

Address

City

Zip Code

Secondary Insurance Information

Name of Insured

Relationship to Insured

Insured SSN or Insurance ID#

Insured Date Of Birth

Employer Name and Address

Address

City

Zip Code

Insurance Company

Address

City

Zip Code

Patient/Legal Guardian Signature

Date