Subscriber ID#:Group #:Phone#:Capitola Dental · P|831-475-2313 · 617 Capitola Ave, Capitola CA, 95010 · capitadental@gmail.com · www.capitoladental.com7/23/2019
Signature will be recorded later.
Authorization (Please read the following information carefully) I grant authority to the Dentist to perform procedures and treatments, including administration of medicine, local and general anesthetics, and extractions along with other surgical and dental procedures that may be necessary. I hereby grant payment of all medical and dental benefits directly to Robert C. Schellentrager, D.M.D.Subscriber Name:Primary Dental Insurance:Secondary Insurance:Phone #:Group #:Subscriber ID#:Subscriber Name:Who is your regular Dentist?What is the reason for your visit today?Insurance InformationSS#:Cell Phone:Home Phone:Zip Code:State:City:Address:Last Name:First Name:DOB:Emergency Patient FormDr. Robert C. Schellentrager DMD General and Cosmetic Dentistry