Health History Form | Dr K Ortho

RESPONSIBLE PARTY INFORMATION

Primary Responsible Party Last

First

Relationship to Patient

Mailing Address Street

City

State

Zip

Home Phone

Cell Phone

Work Phone

How long at this address

Rent Own

E-Mail

Previous Address(If less than 3 yrs)

Street

City

State

Zip

Social Security #

D.O.B

Marital Status

Employer

Occupation

No. of Years Employed

Secondary Responsible Party Last

First

Address (if different from above)

Street

City

State

Zip

Social Security #

D.O.B

Relationship to Patient

Home Phone

Cell Phone

Work Phone

Email Address

Employer

Occupation

No. of Years Employed

INSURANCE INFORMATION

Policy Holder’s Name

ID #

D.O.B

Dental Insurance Company

Group #

Insurance Co. Address

Insurance Co. Phone

Policy Holder’s Employer

Do you have Dual Coverage

Yes No

If Yes

Policy Holder’s Name

ID #

D.O.B

Dental Insurance Company

Group #

Insurance Co. Address

Insurance Co. Phone

Policy Holder’s Employer

By signing below I authorize release and electronic submission of any information relating to my dental claims. I am assigning insurance benefits payable to Dr. Tatyana Kaganova, c/o Dr. “K” Orthodontics. I understand that where appropriate, credit bureau reports may be obtained.

Signature (Parent’s sign if minor)

Date

Health Questionnaire

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION