Lannie Zarate-Reyes, D.D.S., Inc.

579 Coleman Avenue, Suite 10

San Jose, CA 95110

408.588.1271

 

Patient Information:

 

 

Last Name                                             First Name                                                            MI

                                                                                                                                                 

Nickname                                              Birth Date                                                              Social Security #

 

Address                                                  Street                      City                         State                       Zip

               

Home Phone                                          Cell Phone                                                             Email

 

Work Phone                                          Employer

 

Marital Status (single, married, divorced, separated)                    Student (Y/N)      School Name & Address

 

Dental Insurance Information: (Primary Insured)

 

 

Last Name                                             First Name                                                            MI

 

Social Security #                                   Birth Date                                                              Driver’s License/ID #

 

Employer                                               Occupation                                                           Length of Employment

 

Employer Address                               Street                      City                         State                       Zip

 

Insurance Carrier                                                                  Group/ID#

 

Insurance Mailing Address                                                Telephone #

 

Please list below if you have any other Dental Insurance: (Secondary Coverage)

 

 

Last Name                                             First Name                                                            MI

 

Social Security #                                   Birth Date                                                              Driver’s License/ID #

 

Employer                                               Occupation                                                           Length of Employment

 

Employer Address                               Street                      City                         State                       Zip

 

Insurance Carrier                                                                  Group/ID#

 

Insurance Mailing Address                                                Telephone #

 

 

Referral Information: (Pass by, Web Site, Employee, Co-worker, Friend) ___________________________________

 

I hereby authorize the release of any information including the diagnosis and the records of any treatment, or examinations rendered, to my insurance company or companies.  This release is solely for the purpose of facilitating the billing and reimbursement, directly to the dentist, of insurance benefits under which I am entitled.  Authorization is hereby granted to Equifax and Lannie S. Zarate-Reyes, D.D.S., Inc. to release information for appropriate credit verification and patient information required.

 

 

Signature of Patient/Guardian                           Signature of Responsible Party                          Date

 

 

 

 

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