Health history and insurance form | Garfinkle Orthodontics

503.246.9802

info@garfinkleortho.com

HEALTH HISTORY AND INSURANCE UPDATE

PATIENT INFORMATION

Patient's Legal Name:

Patient's Biological Sex:

Patient's Preferred Name:

Patient's Preferred Pronouns:

Patient's DOB:

Address:

Primary phone:

Primary email:

Who is legally responsible for patient:

Dentist Name:

Any changes to health history? Yes No

Please explain:

PARENT/GUARDIAN #1

Name:

Relationship:

DOB:

Address:

Same as patient? (check if yes)

Email (for appt reminders):

Home Phone:

Cell Phone:

Marital Status:

PARENT/GUARDIAN #2

Name:

Relationship:

DOB:

Address:

Same as patient? (check if yes)

Email (for appt reminders):

Home Phone:

Cell Phone:

Marital Status:

DENTAL INSURANCE INFORMATION

In order to check benefits/bill insurance, we need a copy of your dental insurance card and the below information completed. Please text or email front/back photo of your dental insurance card to 503.246.9802 or bring the card to your appointment.

PRIMARY DENTAL INSURANCE:

Name of Insurance Company:

Phone:

Insurance Address:

Subscriber’s Name:

SSN:

Sub ID:

Subscriber DOB:

Group or Policy Number:

Patient's Relationship to Subscriber:

Self

Spouse

Dependant

SECONDARY DENTAL INSURANCE:

Name of Insurance Company:

Phone:

Insurance Address:

Subscriber's Name:

SSN:

Sub ID:

Subscriber DOB:

Group or Policy Number:

Patient’s Relationship to Subscriber:

Self

Spouse

Dependant