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Serramonte Dental Group
1101 El Camino Real
San Bruno, CA 94066
PATIENT NAME:
(
)
PATIENT NAME:
Last
First
Nickname
AGE
BIRTHDATE
SOCIAL SECURITY NO.
HOME ADDRESS
CITY
STATE
ZIP
HOME PHONE
WORK PHONE NO.
CELL PHONE NO.
E-MAIL
IF CHILD, PARENT'S NAME
PHONE NO
IN CASE OF EMERGENCY NOTIFY
PHONE NO
NAME OF SPOUSE
PERSON RESPONSIBLE FOR ACCOUNT
PATIENT(OR PARENT, IF CHILD)
SPOUSE
OCCUPATION
EMPLOYER
EMPLOYER'S ADDRESS
EMPLOYER'S PHONE NO.
IF YOU HAVE DENTAL INSURANCE THE FOLLOWING MUST BE COMPLETED IN ORDER TO PROCESS YOUR FORMS:
PRIMARY
SECONDARY
NAME OF INSURED
SOCIAL SECURITY NO.
CARRIER NAME
CARRIER ADDRESS
UNION, GROUP OR POLICY NO.
PHONE NO.
IF OVER 18 AND INSURED UNDER PARENT'S POLICY INDICATE STUDENT STATUS:
FULL TIME STUDENT
PART TIME STUDENT
NOT A STUDENT
NOTE: IF YOU HAVE INSURANCE, WE WILL ASSIST YOU IN COMPLETING THE NECESSARY FORMS. HOWEVER, WE MUST STRESS THAT YOU ARE RESPONSIBLE FOR THE ENTIRE BILL OUR ROLE IS ONLY TO HELP YOU PROCESS YOUR INSURANCE FOR PAYMENT. WE CAN NOT BE RESPONSIBLE FOR ANY FAILURE OF YOUR INSURANCE CARRIER TO PAY FOR THE TREATMENT.
WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
I HEREBY AUTHORIZE ALL DENTAL DIAGNOSTIC PROCEDURES FOR MYSELF OR MY CHILD. IF I DECIDE TO PROCEED WITH TREATMENT, I ALSO CONSENT TO SUCH METHODS, DRUGS AND AGENTS AS MAY BE INDICATED WITH SUCH CARE. THIS CONSENT SHALL REMAIN IN EFFECT UNTIL CANCELLED IN WRITING.
Signature
Relationship to child (if appicable)
Date
Patient Validation:
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