New Patient Information - Smiles By Glerum

Last Name:*
Last
First:*
First
Preferred or Nickname:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone:*
Work Phone:
Cell phone:
SS#
Date of Birth:
Sex:*
- M
- F
Marital St:
Email Address:

SECONDARY INSURANCE COVERAGE:
(if applicable)
Policy holders Name:
First
SS#
DOB:
Member ID#:
Group ID#:
Insurance Company:
Employer Name:
Assignment and Release: I certify that I, and/or my dependent(s), have insurance coverage with the above listed insurance company(ies) and assign directly to Dr. Karen Glerum all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of all my signature on all insurance submissions. The above named dentist may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services determining insurance benefits of the benefits payable for related services.
Patient Signature:
Date:

Smiles By Glerum