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Please check the option which you prefer. Payment in full at each appointment. __ Cash __ Personal Check __ Credit Card (Visa, Mastercard and Discover) (There will be a $30 Service Charge for ALL returned checks) I agree to be responsible for payment of all services rendered on my behalf or on behalf of my Dependents. Signature of responsible party __________________________________ Date__________________________ ___________________________________________________________________________________________________________________________________ Please fill out other side if you have insurance information. Insurance Information Name of Policyholder ______________________________ Birthdate _________________________________ SSN _______________________ Relationship to Patient ___________________________________________ Employer __________________________ Work Phone # ____________ Date of employment _____________ Insurance Company ____________________________ Group Number ________________________________ Insurance Phone # _____________________________ Employee Number _____________________________ ____________________________________________________________________________CHNKWKS 8øÿÿÿÿTEXTTEXTö"FDPPFDPP&FDPPFDPP(FDPCFDPC*STSHSTSH,STSHSTSH,2SYIDSYIDP,SGP SGP d,INK INK h,BTEPPLC l, BTECPLC Œ,FONTFONT¤,<STRSPLC à,:PRNTWNPR-è FRAMFRAM7ˆTITLTITLŠ7*DOP DOP ´7Driver s license # _________________CONFIDENTIAL Patient Registration Information Please Print Date_____________ Doctor of Preference: __ Dr. Zapata __ Dr. G. Hall __ Dr. N. Hall __ No Preference Name_______________________________________________ SSN____________________ __ Male __ Female Welcome to our practice! Thank you for selecting our dental healthcare team. Please fill out this form completely in ink If you have any questions or concerns, Please do not hesitate to ask for assistance - we will be happy to help. Home address_____________________________ City___________________ State_____ Zip____________ Birthdate____________ Home #_______________ Work #______________ Cell #_____________________ Do prefer to receive calls at: __ Work __ Home __ Cell ____________________________________________________________________________________________________________________________________ Are you: __ Minor __ Single __ Married __ Divorced __ Widowed __ Separated You or your parent/guardian s employer _______________________________ Work # __________________ Spouse or parent/guardian s name_________________ Employer________________ Work #____________ College students: College____________________ City&State ________________Full/Part Time __________ Person to contact in case of emergency ___________________________________ Phone # ________________ ____________________________________________________________________________________________________________________________________ Responsible Party Name of person responsible for this account ______________________________________________________________________________________ Authorization, Release, and Agreement to Pay for Services Rendered I authorize the dentists to release any information including diagnosis and the records of any treatment or Examination rendered to me during the period of such dental care to third party payers and/or other health Practitioners. I authorize and hereby request my insurance company to pay directly to the dentist (or dental group) Insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be Responsible for payment of all services rendered on my behalf or on behalf of my dependents. __________________________________________________ _____________________________________ Signature of responsible party Date at each appointment. __ Cash __ Personal Check __ Credit Card (Visa, Mastercard and Discover) (There will be a $3O‚„jl r¤¶HJ  ÌÎJ T V   Ü Þ ¦ ¨ t v >Hl8:öøº¼†ˆDFÎüþÖ ¾T*,ðøt ¢df(*ê쨪hrtúüÔª È Ê ”!ì!î!È"‚#„#<$ò$øôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôôò$ô$ö$ØØ(2‚"'(Š  Û) @·S Ah‚„jl¤HJ  ÌÎJ V   Ü Þ ¦ ¨ t v >Hl8:öøº¼†ˆDFÎüþÚ*ðø df(*ê쨪hrtúüÈ Ê ì!î!¬"<$ò$ö$îÞ̺ުޠªÞªÞªÞºÞªÞªÞªÞªÞºÌÞªÞªÞªÞªÞªÞ̺ÞÌÞªÌÞªÞªÞªÞªÞºÞ̪ުުÞÌÞ  "  "àŒ"  "àŒ"  "PS"  "PS"  "ˆ¶"  Ôä¹ÄÿÿÿÿÔä$Ç "ð " ttò$ö$&(ö$*(ÜäÎÃTimes New Romanÿy " " "¤øÃìÈXX–(–,8ˆLexmark 5600-6600 Series (Netw𤜜Ÿê oXä ö ÿÿÿÿÿÿ(NONE)vp@Ù{vå—å—ÊÖ{v çÖ{v¼å—`M(8×{vNqwòžât€-ÿ4å— …vpð,`M( Â "ArialÇTqw2(NONE)vp@Ù{vå—å—ÊÖ{v çÖ{v¼å—`M(8×{vNqwòžât€-ÿ4å— …vpð,`M( Â "ArialÇTqw2𤗼Lexmark 5600-6600 Series8𤗼ÿXÿÿcøöpàSoftware\LexmarkInkjetÿÿÿÿþÿüÿXX,XXXX,XÀXXXX°𤗼4winspoolLexmark 5600-6600 Series (Network)5600-6600_Series_582E72_P1Fÿÿ"|¾"€‘"À¸r"$c"ð` "ð`""A."@ÿÿ"|¾"ðù"À¸r"$c"ð` "ð`"."Patient Info Rev.wps"ø|"ø| (" r Examination rendered tþÿ ÿÿÿÿ²Z¤ žÑ¤ÀO¹2ºQuill96 Story Group Classÿÿÿÿô9²qy¼þ±y¼þ± y¼þ±¼þ±y¼þ±¼þ±…y¼þ±¼þ±y¼þ±…¼þ±Æ y¼þ±Ð ¼þ± y¼þ±