Capitola Registration forms
Dental Health History
HIPPA
Medical History New Patient
(Please Provide Ins. Card and Photo I.D.) I authorize Capitola Dental to bill my insurance company for all services rendered and authorize payment to go directly to office. I authorize the use of my signature on all insurance submissions.
Signature will be recorded later.
Insurance Information and/or Responsible Party for Account:
First Name:
MI:
Preferred Name:
Date of Birth:
Last Name:
S.S.#
City:
Address:
Phone #:
Ins. Company:
Home Phone:
Emergency Contact:
Zip:
State:
How were you referred to our office?
Member I.D.#
Group #
Best Way to reach you: E mail________ Text_____Phone Call______
Address:
S.S. #
Cell Phone:
Subscriber Name:
Email:
Work Phone:
Relationship to Patient:
Employer:
Date of Birth:
Child
Single
Divorced
Married
Hafid Ortega, DDS Tara Vattadi, DDS Robert Schellentrager, DMD