Patient Registration • Knoxville Dentist

Patient Name*
First Last
Nickname
Address*
Street Address City State ZIP Code

*Please include Apartment Number in the Street Address Field
Employer
Occupation
Home Phone
Work Phone
Work Phone Extension
Cell Phone
Birth Date
Social Security Number
Drivers License Number
Email*
Gender
Marital Status
In Case of Emergency, Contact: Name
First Last
In Case of Emergency, Contact: Phone
I would like to receive correspondence via e-mail
I would like to receive correspondence via text message
Who can we thank for referring you to Malone Denstistry?

I understand the responsibility for payment of dental services provided in this office for myself and my dependents is mine. It is due and payable at the time services are rendered. Dr. Malone's office will file all dental claims less than $200.00. All insurance co-pays and deductibles are due at the time of service. Dr. Malone's office will assist me by providing all the information necessary for me to file my dental claims over $200.00. I further understand that a 1.75% finance charge (21% annually) or a $2.00 billing charge (whichever is greater) will be added to any balance over 90 days. In the event of default, I promise to pay legal interest on the indebtedness, together with such collection costs and attorney fees as may be required to effect collection of this note.
Name*
First Last
Date*
Relationship to Patient*