Waterboro Dentist

New Patient Registration
& Financial Form



Name:*
DOB:*
Address:*
E-mail:
Home Phone:
-
Cell Phone:
-
Texting Capable:
Work Phone:
-
Social Security No:
Employer:
Position Title:
Employment Date:
If Child, Parents Names:
If Student, School Name:
Spouse Name:
Spouse DOB:
Spouse SSAN:
Spouse Employer:
Employer:(1)
Spouse Employment Date:
OtherEmergency Contact/Phone:

Account balances over 60 days will incur a 1.5% finance charge.

I understand I am responsible for all costs of dental treatment and I understand that my dental insurance carrier may pay less than the actual bill.  I hereby authorize Waterboro Dentist to administer such medications and perform such diagnostic and therapeutic as may be necessary for proper dental care.  The information is correct to the best of my knowledge and the electronic submission of this form constitutes my electronic signature and authorization to proceed.

Digital Verification: