Patient Information:
Name:______SS#______
Address: ______City ______State______Zip______
Phone #______Cell #______
Sex: Male____ Female_____ Birthdate______
Married _____ Single_____Divorced_____Widowed_____Separated_____
Occupation______
Employer______
Employer Address______
Bus. Phone______
Who can we thank for referring you ______
In case of emergency notify______
Phone #______
Email Address: ______
Primary Dental Insurance:
Person responsible for the account______
Relation to patient______Birth date______SS#______
Insurance Company______
Ins. Co. Phone # ______Id #______Group#______
Address______
Employer______
*Please give your insurance card to the front desk person to copy.
Primary Health Insurance:
Health Insurance Co______
Group #______Id #______Phone #______
Subscribe Name______SSN#______
Relationship to patient______
Employer______
DOB______Occupation______
Phone #______
*Your payment responsibility is to this office. The insurance company will reimburse you. We will file a maximum of two submissions per insurance claim. It is the patient’s responsibility for any fees incurred at the time of the appointment. Please speak to the financial person for arrangements.