Nomi Lee D.D.S

1636 E Washington St, Colton, California 92324 USA

909-825-3210

PATIENT INFORMATION (CONFIDENTIAL)

NAME
DATE
ADDRESS
CITY
STATE/ PROV
ZIP/ P.C
E-MAIL
CELL PHONE
HOME PHONE
SS#/SIN
BIRTHDATE
CHECK APPROPRIATE BOX:

IF COLLEGE STUDENT, F.T. / P.T

NAME OF SCHOOL
CITY
STATE/ PROV

PATIENT'S OR PARENTS/GUARDIAN'S EMPLOYER
WORK PHONE
BUSINESS ADDRESS
CITY
STATE/ PROV
ZIP
SPOUSE OR PARENTS/GUARDIAN'S NAME
EMPLOYER
WORK PHONE
WHOM MAY WE THANK FOR REFERRING YOU?
PERSON TO CONTACT IN CASE OF AN EMERGENCY
PHONE
RESPONSIBLE PARTY
NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT
RELATIONSHIP TO PATIENT
ADDRESS
HOMEPHONE
DRIVER'S LICENSE #
BIRTHDATE
SS#/SIN
EMPLOYER
WORK PHONE
IS THIS PERSON CURRENTLY A PATIENT IN OUR OFFICE
INSURANCE INFORMATION
NAME OF INSURED
RELATIONSHIP TO PATIENT
BIRTHDATE
SS#/ SIN
DATE EMPLOYED
NAME OF EMPLOYER
UNION OR LOCAL #
WORK PHONE
EMPLOYER ADDRESS
CITY
STATE/ PROV
ZIP/ P.C
INSURANCE CO.
TEL.#
GRP #
POLICY/ I.D.#
INS. CO. ADDRESS
CITY
STATE/ PROV
ZIP/ P.C
HOW MUCH IS YOUR DEDUCTIBLE?
HOW MUCH HAVE YOU USED?
MAX ANNUAL BENEFIT?
DO YOU HAVE ANY ADDITIONAL INSURANCE?

IF YES COMPLETE THE FOLLOWING

NAME OF INSURED
RELATIONSHIP TO PATIENT
BIRTHDATE
SS#/ SIN
DATE EMPLOYED
NAME OF EMPLOYER
UNION OR LOCAL #
WORK PHONE
EMPLOYER ADDRESS
CITY
STATE/ PROV
ZIP/ P.C
INSURANCE CO.
TEL.#
GRP #
POLICY/ I.D.#
INS. CO. ADDRESS
CITY
STATE/ PROV
ZIP/ P.C
HOW MUCH IS YOUR DEDUCTIBLE?
HOW MUCH HAVE YOU USED?
MAX ANNUAL BENEFIT?

SIGNATURE OF PATIENT

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DATE:

PARENT/ GUARDIAN IF MIN0R

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DATE

Privacy Practices Documentation

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Patient's Name
DOB:

Signature

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DATE

To Be Completed by Front Office

Written acknowledgement could not be documented due to: