VIRGINIA PADUA MATTSON, D.M.D. 11717 Bernardo Plaza Ct, Suite 100, San Diego, CA 92128 www.vpmattsondmd.com   Telephone: 858.673.1633

Patient Registration

Today's Date   Home Phone

PATIENT INFORMATION

First Name Last Name MI SSN

Address City State Zip

Sex Male Female Age Birth Date Single Married Widowed Separated Divorced

Patient Employed by Occupation

Business Address Business Phone

Whom may we thank for referring you?

Emergency Contact Phone

PRIMARY INSURANCE

Person Responsible for Account: First Name Last Name MI

Relationship to Patient Birth Date SSN Phone

Address City State Zip

Person Responsible Employed by Occupation

Business Address Business Phone

Insurance Company

Contract # Group # Subscriber #

Names of other dependents covered under this plan

ADDITIONAL INSURANCE

Is patient covered by additional insurance? Yes No

Subscriber Name: First Name Last Name MI

Relationship to Patient Birth Date SSN Phone

Address City State Zip

Subscriber Employed by Business Phone

Insurance Company

Contract # Group # Subscriber #

Names of other dependents covered under this plan

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with Name of Insurance Company and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature   Relationship   Date

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