Confidential Patient Information – I

631-766-7328 | 516-639-6975East Setauket Massapequa

	
Confidential Patient Information – 1 of 2
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Personal Information
	
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(Home)
			
 (Work)
			
(Cell)
			
e-mail:
			
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Referred by:
	
Person Responsible for Account
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 Relationship:
	
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(Home)
	
 (Work)
	
Dental Insurance Information
 Primary Insurance Co:
	
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Employer:
	
Policy #:
	
Secondary Insurance Co:
	
Insurance Co. Address:
	
Employee:
	
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I understand that payment is my obligation regardless of insurance or any other third-party involvement.
PATIENT’S NAME
	
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GentileDentalCare

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

516-639-6975

631-766-7328

info@gentiledentalcare.com

gentiledentalcare.com

Our Awards

gentiledentalcare is a multiple award winner

Best Patient Care 2017

Best Practice & Team 2016

Best Patient Care 2014

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.