Online Registration

Online

Patient Registration

Yenzer Family Dental

17600 Chesterfield Airport Rd

Chesterfield MO 63005

Phone: 1-636-778-3019 Fax: 1-636-778-3332

Patient Information

First Name:*

Last Name:*

Birth Date:

Gender:

Pref. Phone:

Home

Work

Cell

Home Phone:

Work Phone:

Cell Phone:

Address 1:

Address 2:

City:

State:

Zip:

Email Address:

Insurance

Relation to Policy Holder:*

Policy Holder's Name:*

Policy Holder's Birth Date:*

Insurance Company:*

Ins. Co. Phone:

Employer:*

P. Holder's Work Phone:

Group #:

P. Holder's Insurance ID:

Ins. Co. Address 1:

Ins. Co. Address 2:

Ins. Co. City:

Ins. Co. State:

Ins. Co. Zip:

Referral

Referral Name:*

Check here to keep your personal information on this computer. Your information will only be applied on MOGO's Online Forms for future use.

Additional Questions
Additional Questions

PLEASE EMAIL OR TEXT US A COPY OF YOUR MOST RECENT DENTAL INSURNACE CARD.

DID YOU EMAIL OR TEXT US YOUR DENTAL INSURNACE INFORMATION?*

Yenzerdental@gmail.com

TEXT: (636)778-3019

In the event of emergency, who should we contact? Name and number

SSN *

Do you have secondary insurance?

Yes

Secondary insurance

Seconday Subscriber Name

Secondary Subscriber ID/Soc. Sec #

Secondary subscriber date of birth

Secondary group number

Secondary insured's employer

Secondary insurance Co phone number

Please initial EACH line to acknowledge that you have read and understand our office policies. These guidelines are in place to provide our patients with the highest level of care and service.

Office appointments which are cancelled with less than 24 hours notification may be subject to a $25.00 cancellation fee per person. Patients who do not show up for their appointment without a call to cancel an office appointment will be considered as NO SHOW and will be subject to a $25.00 fee per person.*

We are only “In-Network” with Delta Dental Premier. All other plans will be considered “Out-of-Network.” This means that if there is any difference between our fees and the fees set by the insurance company/employer, the remaining balance becomes the patients’ responsibility*

If the procedure you are having completed has a deductible, you are responsible for that amount on the day of service and any additional amount based on your plan benefits, if any additional fees remain left over after the insurance pays will be patient responsibility.*

DMO/DHMO/Medicare/Medicaid Plans do not offer any ‘Out-of-Network’ benefits. You will be responsible for all charges incurred.*

It is your responsibility to know how your insurance policy works. Unfortunately all plans are different and we cannot know the details of your plan.*

We will ask to see your insurance card at every visit. We do this so we can bill correctly. We need to review the card even if it has not changed. If you don’t have your most updated card and the charges for your visit are denied by your insurance company, you will be responsible for the balance.*

You will be mailed a bill for any balance on your account. This bill will be due immediately upon receipt. If the bill goes unpaid for 60 days, your account may be subject to our collection agency and credit bureau for further action. There will be an additional 25% collection fee added to the outstanding balance due.*

We accept cash, check, Visa, MasterCard, and Discover and American Express.*

As a courtesy, we try to confirm your upcoming appointments. Circumstances do not always allow us to reach you. Therefore, please do not count on us to remind you of an appointment. If you have questions about the date or time please call.*

Your signature below signifies your understanding and willingness to comply with these policies and procedures.*