PATIENT INFORMATION

Date:

PATIENT INFORMATION

Name:

Gender:

Male Female

Address:

Employer:

Occupation:

Birth Date:

Driver's License:

Telephone:

SSN:

Business/Cell:

Email Address:

Emergency Contact Name:

Phone:

DENTAL INSURANCE INFORMATION

Primary Carrier Company Name:

Address:

Policy Number:

AUTHORIZATION

I hereby authorize payment directly to Christopher Stellpflug, D.D.S. of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost and dental treatment. I hereby authorize Christopher Stellpflug, D.D.S. to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history are correct to the best of my knowledge.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

OTHER INFORMATION

Spouse/Responsible Person Name:

Address:

Employer:

Driver's License:

Birth Date:

Occupation:

Telephone/Business/Cell:

SSN:

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