Adult Patient Registration Form

Fill the form and submit it online or Click Here to download PDF

Adult Verification Form

Today's Date:
MinorSingleMarriedDivorcedWidowedSeperated
Full TimePart Time

Responsible Party

Individuals to whom information may be given regarding your dental records and issues:


Insurance Information

I understand that Mcllwain Family Dentistry is not a contracted provider for my insuarance company and that MFD will be filing to my insurance company as a courtesy and expect their payment on 30 days. I recognize that it is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by the insurance company.

I hereby assign all dental and/or surgical benefits, to include major medical benefits to which I am entitled, including private insurance and other health plans to: McIlwain Family Dentistry, Inc. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorise said assigns to release all information necessary to secure the payment.

Authorization and Release

I certify that the above questions have been accurately answered and the information is correct to the best of my knowledge. Our notice of privacy practices provides information about how we may use and disclose protected health information about you. The notice contains a Patients Rights section describing your rights under the law. You have the right to review our notice before signing this Consent. The terms of our notice may change. If we change our notice, you may obain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in regards to your prior Consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Patient Medical History

Date of last exam:

1. Are you having any dental concerns?

2. Are you under medical treatment now?

3. Have you been hospitalised for any reason?

4. Are you taking any medication?

5. Do you use tobacco products?

6. Do you use alcohol?

7. Do ou use controlled substance?

8. Are you allergic or had any reaction to the following:

Do you have any of the following?

9. Women only

Do you have any of the following?

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