Island Dental
Center of Summerlin
Michael J. Tomita, D.D.S. & Stan S. Askew, D.D.S.
IF
THIS APPT.
IS FOR YOU
START HERE
Name:
DENTAL INSURANCE
PRIMARY CARRIER
Insurance Company:
Group No:
Employers Name:
Insured's Name:
DOB (MM/DD/YY):
Relationship to patient:
Insured's I.D. No:
Insured's S.S. Number:
SECONDARY CARRIER
Insurance Company:
Group No:
Employers Name:
Insured's Name:
DOB (MM/DD/YY):
Relationship to patient:
Insured's I.D. No:
Insured's S.S. Number:
.
Last
First
MI
Address:
City:
State:
Zip:
Home
Phone:
Birthday:
Age:
Male:
Female:
Married:
Single:
Divorced:
Widowed:
Social Security No:
IF
THIS APPT.
IS FOR YOUR CHILD
START HERE
Date:
MM/DD/YY
Last Name:
First:
MI:
Address:
City:
State:
Zip:
Home Phone:
Birthday:
Age:
Male:
Female:
School:
Social Security:
If your child's last name and/or address are
not the same as yours, fill in the top box.
.
ACCOUNT INFORMATION
PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
Name:
Relationship to patient:
Social Security No:
Address:
City:
State:
Zip:
Phone number:
YOU
Name:
Occupation:
Employers name:
Address:
City:
Phone number:
Fax Number:
YOUR SPOUSE
Name:
Occupation:
Employers name:
Address:
City:
Phone number:
Fax number:
GETTING TO KNOW YOU
Is another member of your family or relative a
patient at our office?
Name:
Relationship:
You were referred to us by:
Your former address:
City:
State:
Zip:
Person to contact in emergency:
Phone number:
Address:
City:
State:
Zip:
Closest relative not living with you:
Phone number:
Address:
City:
State:
Zip:
NOTE:
Please print this form, fill out and either mail
it to our office, fax it to our office or bring it in
when you come in for your appointment. Remember
to fill out all 5 forms.
