Teledentistry Patient Registration Form

1. Personal Information

2. Contact Information

Primary Address

Mailing Address (if different)

Phone Numbers

3. Emergency Contact Information

Primary Emergency Contact

Secondary Emergency Contact

4. Insurance Information

Primary Dental Insurance

Secondary Dental Insurance (if applicable)

Medical Insurance

5. Referral Information

6. Appointment & Communication Preferences

Preferred appointment times

Preferred days

Teledentistry platform preferences

Reminder preferences

7. Technology Information

8. Financial Information

Preferred payment method

Credit card information (for deposits/copays)

9. Legal Guardian Information (if patient is minor)

Second Guardian/Parent

Custody Information

10. Marketing & Communication Consent

Preferred communication method for marketing

11. Authorization & Signature

• I certify that the information provided is true and complete.
• I am financially responsible for all services provided, and payment is due at time of service unless arranged otherwise.
• I will provide 24-hour notice for cancellations; a fee may apply for missed appointments.
• I authorize Your Smile Partners PLLC to perform necessary teledentistry services.

If signed by guardian/representative

12. Office Use Only

Thank you for choosing Your Smile Partners PLLC for your teledentistry needs. We look forward to providing you with exceptional virtual dental care. If you have any questions, please contact us at talk@yoursmilepartners.com.