PATIENT APPOINTMENT & INSURANCE FORM
O18
Assigned Student
Date of appt:
-
Month
-
Day
Year
Date
Time of appt:
Hour Minutes
AM
PM
AM/PM Option
what type of patient are you?
New
Patient of record
Today's Date:
-
Month
-
Day
Year
Date
If changing app't old date:
Pt. Name:
Personal Patient?
Y
N
Pt. Hm Phone:
Format: (000) 000-0000.
Wk Phone
Format: (000) 000-0000.
Mobile
Format: (000) 000-0000.
Email:
example@example.com
Address:
City
Zip
Date of Birth
-
Month
-
Day
Year
Date
Do you have Dental Insurance:
Y
N
If YES, please complete insurance information below
INSURANCE INFORMATION
Subscriber (Primary) name
Gender of Primary: 0
Subscriber's Birth date:
-
Month
-
Day
Year
Date
Name of Employer:
Group #
Member ID #:
(NOT SS#)
Name of Dental Insurance:
Provider Service Phone #:
Format: (000) 000-0000.
DSHS (aka Apple Care) #:
WA
If you have co-insurance (dual), please complete the steps for secondary insurance Name of Dental Insurance:
Provider Service Phone #:
Format: (000) 000-0000.
Member ID # (off insurance card):
DSHS (aka Apple Care) #:
WA
Rev July 2023
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