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Western dental referral form

Patient Information Sheet - Western Dental 2025

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The document is a comprehensive Patient Information Sheet from Western Dental Services, Inc., detailing patient data collection, financial responsibility, consent for treatment and communication, and an arbitration agreement. It includes sections on medical history, insurance information, emergency contacts, and privacy practices in compliance with HIPAA. Additionally, it provides a Dental Materials Fact Sheet discussing the safety and risks associated with various dental filling materials. The document emphasizes patient rights regarding health information and outlines procedures for handling disputes through arbitration.

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Click ‘Get Form’ to open the Patient Information Sheet in the editor.
Begin by entering your personal details in the 'Patient Information' section. Fill in your first name, middle initial, last name, and date of birth. Ensure accuracy as this information is crucial for your medical records.
Next, provide your contact information including home phone, cell phone, and email address. Select your preferred communication method for clinical information from the options provided.
Complete the 'Medical Insurance' section by entering details about your insurance carrier and policy number. If applicable, include secondary insurance information.
In the 'Emergency Contacts' section, list two contacts along with their relationship to you. This ensures that we can reach someone if needed during your visit.
Finally, review all entered information for accuracy before signing at the bottom of the form. Your signature confirms that you understand and agree to the terms outlined.

Start filling out your Patient Information Sheet today for a seamless dental experience!

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Versions	Form popularity	Fillable & printable
2018	4.4 Satisfied (26 Votes)
2015	4 Satisfied (36 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What information is found on the patient registration form for dental?

Information typically noted in the dental record includes: personal data, such as the patients name, birth date, address and contact information including home, work and mobile telephone numbers. the patients place of employment. medical and dental histories, notes and updates.

What is included in the patient record dental chart?

The dental record is your official document that details all diagnostic information, health history, clinical notes, treatment performed, and patient-related communications that took place in the practice.

How long has Western Dental been around?

It was founded in 1903 in Los Angeles. Western Dental has almost 250 offices in California, Arizona, Nevada, and Texas, making it one of the largest dental service providers in the United States.

What information is included on the patient registration form?

A patient registration form collects essential information such as personal details, medical history, contact information, and insurance or billing data. The patient registration process is crucial for collecting accurate personal, medical, and insurance information, ensuring proper care, billing, and legal compliance.

What to bring to Western Dental?

To help us give you the best care possible, please bring: False teeth, retainers, bridges, or any other dental items you use. Insurance cards and a photo ID. A list of your current medications. A way to pay for any co-pays or out-of-pocket costs.