JIM CONGLETON, D.D.S., MS • ROBERT HARRISON, D.M.D., M.S.D.
700 McCarthy Boulevard, New Bern, NC 28562
252-633-0424 • Fax: 252-638-6662
info@coastalpediatricdentistry.com
www.drjimc.com

Patient Registration Form


We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

ALL FIELDS IN RED ARE REQUIRED FOR PROPER ACCOUNT PROCESSING.

Patient Information

Insurance Information

INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize Jim Congleton D.D.S., M.S. to furnish information to insurance carriers concerning my dependent's treatments and I hereby assign to the dentist all payments for his services rendered to my dependents. I understand that I am responsible for any amount not covered by insurance.

Because your child is a minor, it becomes necessary that a signed permission is obtained from a parent or guardian before any dental services can be rendered.
Authorization is hereby granted for dental treatment. I will be responsible for any bill incurred on this child for dental treatment.
In an effort to reduce our billing costs so that we can keep your fees down, we require that all fees or estimated co-payments be made on the day of the appointment.

I will be paying today by:

Office Policies

  1. We require 24 hour notices of a cancellation of appointments. If no notice is given a $25.00 charge will be made for each patient.
  2. If a sedative appointment is cancelled without 24 hour notice or if the appointment is broken, a $50.00 charge will be made for each patient.
  3. As of age 15, most patients will be referred to a general dentist.

Past Medical History

10. Please check if your child has had problems with any of the following:

Past Dental History

25. Please check if your child has had problems with any of the following:

Please click on the human verification checkbox before submitting your form.