Confidential Patient Information – 1 of 2


    Date:


    Personal Information


    Name:
    SS #:


    Address:


    City:
    State:


    Zip:


    Telephone:
    (Home)
    (Work)


    (Cell)
    e-mail:


    Birth date:
    Sex:
    Marital Status:


    Spouse Name:
    Occupation:


    Referred by:


    Person Responsible for Account

    Name:
    Relationship:


    SS #:


    Address:


    City:
    State:


    Zip:


    Telephone:
    (Home)
    (Work)


    Dental Insurance Information

    Primary Insurance Co:


    Insurance Co. Address:


    Employee:
    Relationship:


    S.S. #:
    Employer:


    Policy #:


    Secondary Insurance Co:


    Insurance Co. Address:


    Employee:
    Relationship:


    S.S. #:
    Employer:


    Policy #:



    I understand that payment is my obligation regardless of insurance or any other third-party involvement.

    PATIENT’S NAME
    Date

    Gentile_Dental_Care_Logo
    GentileDentalCare

    A prosthodontist is a dentist who specializes in the esthetic restoration and replacement of teeth.

    Our Awards
    Social Networks

    Our staff is professional and courteous with everyone who walks through our doors. We strive to give exemplary care in our practice by communicating with our patients and agreeing on a treatment plan that best suits them aesthetically, and financially.

    Copyright 2020 by BoldThemes. All rights reserved.