Patient Registration Form – Onalaska and La Crosse Area Dentist

Please complete the following confidential information:

Patient Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer
Occupation
Home Phone
Cell Phone
Work Phone
Email Address
Responsible Party (if patient is a minor)
First Last
Date of Birth
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Primary Dental Insurance Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Subscriber Employee Name
First Last
Subscriber Employer
Date of Birth
Social Security Number
Member #
Group #
Phone
Relationship to Subscriber
Secondary Insurance Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Subscriber Employee Name
First Last
Subscriber Employer
Date of Birth
Social Security Number
Member #
Group #
Phone
Relationship to Subscriber
Person To Contact In Case Of An Emergency*
First Last
Phone*
Is another member of your family a patient of Valley Dental?*
- Yes
- No
If yes, what is their name?