PATIENT INFORMATION

Patient’s Name _________________________________________________________Nickname___________________Sex____

                                                    First                                                Middle                                  Last 

Mailing Address___________________________________________________________________________________________

                                                Street/P.O. Box                                                                          City                                                                State   Zip

Date of Birth_____________________Age_____ Social Security #_________________________Height________Weight_______

Dentist_____________________________Referred By_____________________________Physician_______________________

Home Phone (        )                                          Work Phone (       )                                     Cell (       )                       _              .                          

First Name ______________________________________ Last Name _________________________________________

Marital Status:            Married ___    Divorced ___    Single ___   Separated ___   

Relationship to Patient______________________________________________________________________________

Mailing Address_________________________________________________________________________________________

                                                Street/P.O. Box                                                                          City                                                                State   Zip

Home Phone (       )                                                Work Phone (       )                                    Cell (        )                                     

INSURANCE INFORMATION

IS CLAIM RELATED TO AN ACCIDENT? (If yes, check here) ___

DATE OF ACCIDENT ___/___/___ WORKMAN’S COMP?(Y/N)___ AUTO ACCIDENT? (Y/N)___

I AUTHORIZE RELEASE OF INFORMATION RELATING TO THIS CLAIM AND PAYMENT OF THE INSURANCE BENEFITS OTHERWISE PAYABLE TO ME Drs. Scully, Matheson, Fonseca, and Parworth.

SIGNATURE OF THE PATIENT/INSURED_____________________________________________________________________________________

DENTAL

Policy Holder’s Name_____________________________________ Policy Holder’s Soc. Sec. # ___________________________ Birthdate_____________

Insurance Co.___________________________________________Group #________________________Subscriber #_______________________________

Insurance Co. Address__________________________________________________________________Phone #___________________________________

                                              Street/P.O. Box                                          City                                             State   Zip

Policy Holder’s Employer ________________________________________________________________Do you have other dental insurance?  Yes___  No__

If Yes, Name of Company_________________________________________________________________

                                              Secondary Dental Insurance Company                                                                    

MEDICAL

Policy Holder’s Name_____________________________________ Policy Holder’s Soc. Sec. # ___________________________ Birthdate_____________

Insurance Co.___________________________________________Group #________________________Subscriber #_______________________________

Insurance Co. Address__________________________________________________________________Phone #___________________________________

Policy Holder’s Employer ________________________________________________________________Do you have other dental insurance?  Yes___  No___

If Yes, Name of Company_________________________________________________________________

                                           Secondary Medical Insurance Company