Brent Call D.M.D.

8147 E. Evans Rd #1 Scottsdale, AZ 85260

480-443-3552

About You

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely so that we may take better care of you.

Patient Name:
I prefer to be called
DOB
Age
SSN
Home Address
Home Phone
Work Phone
Email
Employer
Employer's Address
Occupation
How long there?
Where and when are the best times to reach you?
Where is the best place to confirm your appointments?
Who may we thank for referring you?
Other family members seen by us?
ABOUT YOUR SPOUSE
Spouse Name
Employer Name
Occupation

DENTAL INSURANCE

Primary Insurance:

Insurance Co. Name
Phone
Employer Name
Occupation
City
State
Zip
Insurance Co. Ph
Group # (plan, local or policy #)
Insured Name
Insured DOB
SSN
ID #
Insured Employer
Employer Ph
Insured Employer Address

Secondary Insurance:

Insurance Co. Name
Phone
Employer Name
Occupation
City
State
Zip
Insurance Co. Ph
Group # (plan, local or policy #)
Insured Name
Insured DOB
SSN
ID #
Insured Employer
Employer Ph
Insured Employer Address

EMERGENCY INFORMATION

​​​​​​​In the event of an emergency, is there someone who lives near you that we should contact?

Name
Relation
Wk Ph
Hm Ph

I acknowledge that i am responsible for all charges for all services provided to me, including any amount not paid by my insuranee plan or any other plan. If my insurance plan will allow direct payment to Dr. Call, I authorize him to take assignments or any unpaid dental insurance claims. I understand that he has the right to refuse or accept assignments of dental benefits. I agree to forward him any assiged payment I receive for dental care immediately upon receipt of such payments. I also authorize the release fo all dental information necessary for processing insurance claims to my insurers or any third party of their agents.