Greg Miller DDS—Advanced Dental Care

Patient Registration Form

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Responsible Party, if other than Patient

Patient Information

Dental Insurance Information

Medical History:

Although dental personnel primarily treat the area in and around your mouth, it is part of your entire body. Health problems that you may have or medication… [content missing]


I affirm that the information given is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

I also authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. In addition, I authorize release of any information necessary to process dental insurance. I understand that I am responsible for any portion my insurance carrier does not pay.