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®
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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:
Were you refered by another patient or insurance company?
Do you have dental insurance?
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:
Guardian or Other
Primary insurance policy holder social security number if not yourself:
Primary insurance policy holder birthdate, If not yourself:
Do you have secondary insurance?
Social security number of secondary policy holder if not yourself:
Birthdate of secondary insurance policy holder if not your self:
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: