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Patient Enhanced Form March 2024

The document is a patient registration form that collects personal information such as name, date of birth, contact details, emergency contacts, insurance information, and preferred payment methods to process treatment, manage records, and communicate for dental care purposes at Astradental Services Limited.

Uploaded by

Lucy Mutara
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
30 views2 pages

Patient Enhanced Form March 2024

The document is a patient registration form that collects personal information such as name, date of birth, contact details, emergency contacts, insurance information, and preferred payment methods to process treatment, manage records, and communicate for dental care purposes at Astradental Services Limited.

Uploaded by

Lucy Mutara
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PATIENT REGISTRATION

FORM
PATIENT INFORMATION
We collect your data strictly for treatment processing, record management and communication purposes. By filling this form, you acknowledge
the use of this data for these purposes ONLY! Astradental is committed to always upholding the confidentiality of your information.
dd / mm / yyyy
Patient Name: ………………………………………………………….. Date of Birth: ………………………………………….
…………………
Gender: …………………………………………………………………… ID/Passport No: …………..
……………………………………………
Cell Phone No: …………………………………………………………. Email Address:
………………………………………………………….
Area of Residence: …………………………….……………………… Date:
……………………………………………………………………...
Name | Relation | Contact
Emergency: ………………………………………………………………………………………………………………..
v REFERRAL INFORMATION
Can we thank someone for referring you? Or did you find us on your own?

Family Member: Name | Contact. Google YouTube


……………………………………………………..
Name | Contact. Instagram Facebook
Doctor: ..…….
Name | Contac Signage City Clock
………………………………………………………….
Name | Contact. Mobile Clinic School Activation
Pharmacy: ….……………..
………………………………………….
Name | Contact. Wellness
Insurance: ..….…………………………………………………..
TRIAGE: What would like us to check? (for free)
Blood pressure Blood Sugar Oxygen Levels Weight/BMI

Mode of payment
M-Pesa Debit/Credit Card
Name of the Insurance
Insurance ………………………………………………………………..
Please be aware that we collect estimated insurance portions at each visit. Your insurance policy is a contract between you and your insurance company. You are responsible for any unpaid balances, regardless of
the original estimate of insurance benefit. As a courtesy to you we will file your claims with your insurance company. Insurance payments are normally received within 30 to 90 days. Any unpaid balances after 180 days are
your responsibility and are due at that time. All deductibles and co-payments are due at the time of service. A completed claim form or copy of your insurance card will need to be kept on file in our office. We try to answer any
questions you may have about your insurance company; however, you may need to contact your insurance company for additional information. If your insurance changes, it is your responsibility to provide updated
information to our office. Assignment of Benefit: Please read and sign to have our office file your insurance: I authorize the release of information and understand that I am responsible for all costs of dental treatment. I hereby
authorize payment directly to Astradental Services Ltd of the insurance benefits otherwise payable to me.
Signature of Patient or Personal Representative:
_________________________________________________________________

Relationship to Patient: __________________________________________________________________________-


_______________

Welcome to Astradental Services Limited! Your smile is our priority. Rest assured, our
team is dedicated to providing you with exceptional care. Thank you for entrusting us with
your oral health.

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