Your Smile Partners PLLC — Teledentistry Patient Registration Form

Teledentistry Patient Registration Form

Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555-SMILE

Registration Date

Patient ID

1. Personal Information

Full Legal Name

Preferred Name

Social Security Number

Format: 123-45-6789

Date of Birth

Age

Gender

Male Female Non-binary Prefer not to disclose Other

Marital Status

Single Married Divorced Widowed Domestic Partner

Language Preference

English Spanish Other

Occupation

Employer

Work Phone

Extension

2. Contact Information

Primary Address

Street

City

State

ZIP

How long at this address? Years

Months

Mailing Address (if different)

Street

City

State

ZIP

Phone Numbers

Home

May we leave messages?

Cell

May we text?

Work

May we call at work?

Email Address

Appointment reminders via email

Preferred method of contact

Phone Text Email

Best time to contact

Morning Afternoon Evening Anytime

3. Emergency Contact Information

Primary Emergency Contact

Name

Relationship

Phone

Alternate

Address

Secondary Emergency Contact

Name

Relationship

Phone

Alternate

4. Insurance Information

Primary Dental Insurance

Insurance Company

Phone Number

Policy/Member ID

Group Number

Subscriber Name

Subscriber DOB

Relationship to Subscriber

Self Spouse Child Other

Subscriber Employer

Employer Address

Secondary Dental Insurance (if applicable)

Insurance Company

Phone Number

Policy/Member ID

Group Number

Subscriber Name

Medical Insurance

Insurance Company

Policy/Member ID

Group Number

Insurance Authorization

File insurance claims on my behalf Accept assignment of benefits Release necessary information to process claims

Signature (Insurance Authorization)

Date

5. Referral Information

Internet search Google reviews Social media Insurance directory Friend/family referral Healthcare provider referral Advertisement Previous patient Other

If Other

Referring person/practice name

May we thank them for the referral?

6. Appointment & Communication Preferences

Preferred appointment times

Early morning (7-9 AM) Morning (9-11 AM) Midday (11 AM-1 PM) Afternoon (1-4 PM) Late afternoon (4-6 PM) Evening (6-8 PM)

Preferred days

Monday Tuesday Wednesday Thursday Friday Saturday

Teledentistry platform preferences

Zoom Doxy.me Microsoft Teams FaceTime No preference

Reminder preferences

Phone call Text message Email No reminders

24 hours 48 hours 1 week

7. Technology Information

Primary device

iPhone Android phone iPad Android tablet Windows laptop/desktop Mac laptop/desktop Chromebook

Internet connection

High-speed WiFi Mobile data DSL/Cable Fiber optic

Camera quality

HD (1080p) 4K Standard Unsure

Environment

I have a quiet, private space I do not have a private space

I need technical assistance I do not need assistance

8. Financial Information

Employment Status

Full-time Part-time Self-employed Retired Student Unemployed

Payment responsibility

Self Parent/guardian Spouse Insurance only

Preferred payment method

Cash Check Credit card Debit card HSA/FSA Payment plan

Credit card information (for deposits/copays)

Card Type

Visa MasterCard American Express Discover

Number

Expiration (MM/YY)

Name on Card

Billing ZIP

CVV

9. Legal Guardian Information (if patient is minor)

Guardian Name

Relationship

Date of Birth

SSN

Employer

Work Phone

Second Guardian/Parent

Name

Relationship

Phone

Custody Information

Both parents have equal rights Sole custody (specify) Court order on file

10. Marketing & Communication Consent

Appointment reminders Treatment follow-up communications Oral health education materials Practice newsletters Promotional offers Birthday/holiday greetings Patient satisfaction surveys

Preferred communication method for marketing

Email Text message Phone call Mail None

11. Authorization & Signature

I certify that the information provided is true and complete.
I am financially responsible for all services provided, and payment is due at time of service unless arranged otherwise.
I will provide 24-hour notice for cancellations; a fee may apply for missed appointments.
I authorize Your Smile Partners PLLC to perform necessary teledentistry services.

I agree to the Authorization statements above.

Patient Signature

Date

If signed by guardian/representative

Name

Relationship to Patient

Representative Signature

Date

12. Office Use Only

Registration completed by

Date processed

Time

Insurance verified

Date

Technology test completed

Tech test date

Welcome packet sent

Method

First appointment date

Time

Provider assigned

Notes

Thank you for choosing Your Smile Partners PLLC for your teledentistry needs. We look forward to providing you with exceptional virtual dental care. If you have any questions, please contact us at talk@yoursmilepartners.com.

Use “Print Form” for a paper copy, “Save PDF” to store locally, or “Submit & Upload” to save a PDF and go to our secure Dropbox page.

Ready

Patient Registration Form

Teledentistry Patient Registration Form

1. Personal Information

2. Contact Information

3. Emergency Contact Information

4. Insurance Information

Insurance Authorization

5. Referral Information

6. Appointment & Communication Preferences

7. Technology Information

8. Financial Information

9. Legal Guardian Information (if patient is minor)

Second Guardian/Parent

Custody Information

10. Marketing & Communication Consent

11. Authorization & Signature

If signed by guardian/representative

12. Office Use Only

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