Ed Struss Family Dentistry
 
 
Root Canals ● Fillings ● Crowns & Bridges Prophy Services (with Registered Hygienist) ● Dentures ● Digital & Panoramic X-rays ● In-Office & Take-Home Whitening Treatments ● Facings, Veneers, & Lumineers®
 
 
 
 
 
 
Set Your Appointment:
153 Burt Rd, Lexington, KY 40503
 
 
 
 
 
 

Caring Dentist Serving Lexington, KY

 
 

Patient Registration Form

 
 
 
 
 
 
 
 
 
Are you filling out this form for you or someone else:
 
 Self  Someone Else 
 
 
 
 
 
 
 
 
 
 
 
 
Marital Status:
 
 Married  Not Married 
 
 
 
 
 
Sex:
 
 Female  Male 
 
 
 
 
 
 
 
 
 
 
Were you refered by another patient or insurance company?
 
 Yes  No 
 
 
 
 
 
 
 
 
 
 
 
 
 
Employed:
 
 Full-Time  Part-Time  Retired 
 
 
Full-Time student?
 
 Yes  No 
 
 
Do you have dental insurance?
 
 Yes  No 
 
If no, Who is responsible for your bill?
 
 
 
 
 
 
 
If you have dental insurance, Please fill in the following information
 
 
 
 
 
 
 
 
Primary policy holder relationship to patient:
 
 
 
 
 
 
 
 
Primary insurance policy holder social security number if not yourself:
 
 
 
Primary insurance policy holder birthdate, If not yourself:
 
 
 
Do you have secondary insurance?
 
 Yes  No 
 
 
 
 
 
 
 
 
 
 
 
 
 
Social security number of secondary policy holder if not yourself:
 
 
 
Birthdate of secondary insurance policy holder if not your self:
 
 
 
Emergency contact:
 
 
 
 
 
 
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist. I understand that I am financially responsible for any balance. I also authorize Ed Struss DMD or my insurance company (if applicable) to release any information required to process my claims. Please type your signature below:
 
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