New Patient Information Forms




Date____________________                             Patient SS#_________________________


Patient Name_________________________________________________________________

                                      Last                                                             Fiirst                                                          Middle Initial



      P.O. Box not acceptable                                                             City                   State                         Zip___


Email Address ________________________________      Sex:    M          F        __________

                                                                                                    Circle choice                 Age                    

Birthdate______________________      Occupation:_________________________________


Married    Widowed    Single    Minor  Divorced  Home Phone________________Cell_________________

                               Circle choice                 

Employer orSchool___________________________           Work Phone ___________________


Spouse/Partner’s Name________________________           Birthdate_____________________


Ss#of Spouse_____________________      Spouse Employer____________________________


Whom may we thank for referring you?______________________________________________


In case of Emergency we should call:________________________Phone___________________


Who is responsible for payment of the account:________________________________________


Relationship to Patient:________________Primary Dental Ins. CO Name______________________


Ins Group #________________________ Subscriber ID _________________________________


Ins Phone #________________________  Is patient covered by additional ins?       NO      Yes        

Secondary Dental Ins. CO Name______________________Subscriber Name__________________


Ins Group #________________________ Subscriber ID _________________________________


Ins Phone #________________________ Subscriber Birthdate_____________________________


Assignment and Release

I certify that I, and or my dependents have insurance coverage and assign directly to Dr. G’Sell all insurance payments, if any, otherwise payable to me for services rendered.

I acknowledge my understanding that I am financially responsible for all charges whether or not paid by insurance.  I authourize the use of my signature on all insurance submissions.

Dr. G’Sell may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This authorization is in effect for any insurance plan I currently have.

I understand that payment is due at the time of treatment unless otherwise arranged by the office of Dr. G’Sell.  I understand that a billing fee may be applied to any payment arrangement I fail to honor.


_________________________________________       Date______________________


_________________________________________  Relationship to patient_____________


Printed name

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