Capitola Dental · P|831-475-2313 · 617 Capitola Ave, Capitola CA, 95010 · capitadental@gmail.com · www.capitoladental.comDate: 5/24/2019
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Phone #:Authorization (please read following information carefully) I grant authority to the Dentist to perform procedures and treatments, including administration of medicine, local and general anethetics, 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 DMDSubscribers ID#:Group #:Subscribers name:Secondary Dental Insurance:Group #:Phone #:Subscribers ID#:Subscribers name:Primary Dental Insurance:Insurance Information:How do you feel about your teeth?Who referred you to our office?Last dental visit:Previous Dentist:Contact #:Legal Guardian:Phone #:Medical Doctor:Emergency Contact:Email:Work Phone #:Employer:minormarrieddivorcedwidowsingleZip Code:State:City:Address:Cell #:Phone #:SS #:Date of Birth:Nickname:MFirst Name:Last Name:Patient Information FormDr. Robert C. Schellentrager DMD General and Cosmetic Dentistry