Myron Massey DDS

322 N H St, San Bernardino, CA 92410

909-888-1301

Patient Registration

ID:

Chart ID:

First Name:

Last Name:

Patient is:

Policy Holder Responsible Party

Responsible Party (if someone other than the patient)

First Name:

Last Name:

Address:

City:

State:

Zip:

Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Birth Date:

Soc. Sec:

Drivers Lic:

Responsible Party is

Also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Patient Information

Address:

City:

State:

Zip:

Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Sex:

Male Female

Marital Status:

Married Single Divorced Separated Widowed

Birth Date:

Age:

Soc. Sec:

Drivers Lic:

E‐mail:

I would like to receive correspondences via e‐mail

Section 2

Employment Status:

Full Time Part Time Retired

Student Status:

Full Time Part Time

Medicaid ID:

Pref. Dentist:

Employer ID:

Pref. Pharmacy:

Carrier ID:

Pref. Hyg.:

Primary Insurance Information

Name of Insured:

Relationship to Patient:

Self Spouse Child Other

Insured Soc. Sec:

Insured Birth Date:

Employer:

Address:

City:

State:

Zip:

Insurance Company:

Address:

City:

State:

Zip:

Rem. Benefits: .00

Rem. Deduct: .00

Secondary Insurance Information

Name of Insured:

Relationship to Patient:

Self Spouse Child Other

Insured Soc. Sec:

Insured Birth Date:

Employer:

Address:

City:

State:

Zip:

Insurance Company:

Address:

City:

State:

Zip:

Rem. Benefits: .00

Rem. Deduct: .00

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Guardian's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date: