Confidential Registration

Patient Information

Patient Name *

Preferred Name

Sex *

Male

Female

Date of Birth *

SSN

Home Phone

Cell Phone

Work Phone

Name of Employer

Mailing Address

Zip Code

I prefer to be contacted by email

Email Address

Name of Dentist

Primary Care Physician

Pharmacy Name / Location

Responsible Party Information (if patient is a minor)

Responsible Party Name

Relationship to Patient

Address

Zip Code

Phone

Date of Birth

SSN

Insurance Information

Primary Insurance

Dental Insurance Company

Policyholder's Name

Relationship to Patient

SSN

Date of Birth

Member ID

Group Number

Name of Employer

Employer Phone

Secondary Insurance

Secondary Insurance Company

Policyholder's Name

Relationship to Patient

SSN

Date of Birth

Member ID

Group Number

Name of Employer

Employer Phone

Assignment and Release

I understand that I am financially responsible for all charges, whether or not paid by insurance. I, the undersigned, have insurance with:

Insurance Company

I assign directly to Shaun Burlingame, DDS, MD, and/or Francisco Suarez, DDS, all benefits, if any, otherwise payable to me for services rendered. I hereby authorize Shaun Burlingame, DDS, MD, and/or Francisco Suarez, DDS, to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

Date *

Signature *

Name Validation *