(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:ChildSingleDivorcedMarriedHafid Ortega, DDS Tara Vattadi, DDS Robert Schellentrager, DMD