Adult New Patient Information

Adult Registration Form - Dental

Patient Information

Have we treated any other immediate family members?
How did you hear about our Practice?

Spouse / Partner Information

Marital Status

Person(s) OK to release appointment or medically related information to concerning you:

Insurance Information


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Security Measure

Parker Dental

  • Parker Dental - 502 S. Main St., Brownstown, IN 47220 Phone: 812-358-2037 Fax: 812-358-2039

John 15 – "I am the vine; you are the branches. If you remain in me and I in you, you will bear much fruit; apart from me you can do nothing. This is to my Father’s glory."

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