New Dental Patient Registration - Lux Smiles Dental

JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)

7 Gramercy Park West
New York, NY 10003
+1 (212) 777-7126

This online form is primarily for print only, so you can:

Fill out information online, print out the completed form, and sign it at our office; or
Print out a blank form, fill it out and sign it at our office; or
Fill out the forms that we have in the office and sign there.

DENTAL REGISTRATION

1. PATIENT INFORMATION

Date

Patient Name

First Middle Last Suffix

SS/HIC/Patient ID#

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Work Phone

Mobile Phone

Gender

Male
Female
Choose not to specify

Age

Please enter a number from 0 to 122.

Date of Birth (DOB)

Marital Status

Employer/School

Occupation

Employer/School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer/School Phone

Whom may we than for referring you?

In case of emergency, who should be notified?

First Last

Emergency Contact Phone

2. PRIMARY INSURANCE

Person Responsible for Primary Insurance Account

First Middle Last Suffix

Primary Insurance Account Holder (PIAH) Relationship to Patient

PIAH DOB

PIAH Social Security

PIAH Phone

PIAH Address (if different from patient's)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PIAH Employer

PIAH Occupation

PIAH Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insurance Company

Primary Insurance Contract #

Primary Insurance Group #

Primary Insurance Subscriber #

Names of other dependent(s) covered under this primary insurance plan:

First Name	Last Name

3. ADDITIONAL INSURANCE

Is patient covered by additional insurance?

Yes
No

Additional Insurance Subscriber Name

First Middle Last Suffix

Subscriber Relationship to Patient

Subscriber DOB

Subscriber Social Security

Subscriber Phone

Subscriber Address (if different from patient's)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Subscriber Employer

Subscriber Occupation

Subscriber Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Insurance Company

Additional Insurance Contract #

Additional Insurance Group #

Additional Insurance Subscriber #

Names of other dependent(s) covered under this additional insurance plan:

First Name	Last Name

4. ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with the aforementioned Insurance Company(ies) and assign directly to Dr. Jai H. Shin, DDS, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the to the aforementioned Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end and when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Date of signature

Printed name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

JAI H. SHIN, DDS, PLLC & Associates (AKA Lux Smiles)

DENTAL REGISTRATION

1. PATIENT INFORMATION

2. PRIMARY INSURANCE

3. ADDITIONAL INSURANCE

4. ASSIGNMENT AND RELEASE

$250 Dental Cleaning, X-rays & Exam

Normally $500

JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)