Patient Information Sheet-Insurance Information Form

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Lewis D. Gilbert, DDS, Ltd.
Oral & Maxillofacial Surgery
PATIENT INFORMATION SHEET
(ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE)
Patient Name: _______________________________
Parent/Spouse Information
Home Mailing Address: _______________________
Mom/Spouse
Dad
_____________________________________________
Name: ___________________________________
Home Physical Address: _______________________
Address: _________________________________
_____________________________________________
__________________________________________
Home Phone: _______________ Cell: ____________
Phone: ___________________________________
Employer Name: _____________________________
Alternate Phone: __________________________
Date of Birth: __________Sex: Male ___ Female ___
Date of Birth: _____________________________
Social Security Number:
Social Security
_________________________
:_______________________________
Drivers License Number: ______________________
Employer: ________________________________
Marital Status: _____ Single
_____ Separated
_____ Married
_____ Widowed
This signature is my authorization for the release of medical and
_____ Divorced
.
financial information necessary for this office
Is patient a full time student? _____Yes _____ No
Name & address of school: ______________________
Emergency Contact: ___________________________
*Signature: _______________________________
____________
___________
Relationship to Patient:
Phone:
Insurance Information
Primary Medical Insurance
Primary Dental Insurance
Name of Insurance: __________________________
Name of Insurance: ________________________
Subscriber Name: ___________________________
Subscriber Name: _________________________
Relationship to Patient: _______________________
Relationship to Patient: _____________________
Subscriber Date of Birth: ______________________
Subscriber Date of Birth: ___________________
Subscriber Social Security Number: _____________
Subscriber Social Security Number: __________
Subscriber Address (
): ____________
Subscriber Address (
): _________
if different from above
if different from above
_____________________________________________
__________________________________________
Employer’s Name: ____________________________
Employer’s Name: _________________________
Employer’s Address: __________________________
Employer’s Address: _______________________
_____________________________________________
__________________________________________
Employer’s Phone: ___________________________
Employer’s Phone: ________________________
Referring Doctor or Dentist:
_____________________________________________________________
After providing copies of all of your insurance cards to our front
I authorize direct payment of insurance to the providing dentist.
office, please read and sign this form as the guarantor.
Return completed form to the receptionist window.
*Signature: _______________________________

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