Girdwood Insurance

Dental Insurance Information / Release
We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.
Patient Name*

First NameMiddle InitialLast Name
Nickname
Date of Birth*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone*

Area CodePhone Number
2nd/Cell Phone*

Area CodePhone Number
Email*
example@example.com
Insurance Company*
Insurance Claim Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Claim Phone Number

Area CodePhone Number
Insured's Name

First NameLast Name
Insured's Date of Birth
Relationship to Patient
Employer
Group Number
Member ID
Orthodontic LIfetime Maximum
Amount Used to Date
Benefits Payable at (%)
Age Limit
Deductible
Coordination of Benefits
Do you have dual insurance coverage?

YesNo
Secondary Insurance Information
Insurance Company*
Insurance Claim Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Claim Phone Number

Area CodePhone Number
Insured's Name

First NameLast Name
Insured's Date of Birth
Relationship to Patient
Employer
Group Number
Member ID
Orthodontic LIfetime Maximum
Amount Used to Date
Benefits Payable at (%)
Age Limit
Deductible
Coordination of Benefits
E-mail
Should be Empty:

Dental Insurance Information / Release