Health history and insurance form | Garfinkle Orthodontics

HEALTH HISTORY AND INSURANCE UPDATE

Patient’s Name:

Patient’s Birth Date:

Primary Phone Number/type: (i.e., Mom’s cell) :

Primary Email Address:

Current Address:

Current Dentist:

Any changes to health history?

Yes No

Please explain:

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 to your appointment).

PRIMARY DENTAL INSURANCE:

Name of Insurance Company:

Phone:

Insurance Address:

Subscriber’s Name:

SSN:

Sub ID:

Date of Birth:

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:

Date of Birth:

Group or Policy Number:

Patient’s Relationship to Subscriber:

Self

Spouse

Dependant