Date____________________ Patient SS#_________________________
Patient Name_________________________________________________________________
Last Fiirst Middle Initial
Address______________________________________________________________________
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______________________
Signature
_________________________________________ Relationship to patient_____________
Printed name