Welcome to Jeff Velasquez, DDS
New Patient Form - Personal Information

Please fill out this form, check any corresponding box/es that may apply and submit. [Privacy Note: this file is for Velasquez Dental record only.]

mm/dd/yyy

Name (Last, First & MI)

Address (Street #, City, State, ZIP)

e-Mail Address

Home phone

Mobile Phone

Work Phone

Occupation

Referred by:

Employer

Employer's address (Street #, City, State, ZIP)

status








Spouse name

Do You Have chidren




how Many children do you have

Do you have Insurance coverage?





Primary Insurance

Company Name (primary Insurance)

Company Address-Primary Insurance (Street #, City, State, ZIP)

Phone (Primary Insurance)

Insured's Name (Primary Insurance)

Group # -Primary Insurance (Plan, Local, or Policy #)

Relation to the insured (Primary Insurance)

Insured's Date of Birth (Primary Insurance)

Insured's Employer (Primary Insurance)

Secondary Insurance

Company Name - Secondary Insurance (Last, First & MI)

Company Address - Secondary Insurance (Street #, City, State, ZIP)

Phone (Secondary Insurance)

Insured's Name (Secondary Insurance)

Insured ID# (Secondary Insurance)

Group # - Secondary Insurance (Plan, Local, or Policy #)

Insured's Name (Secondary Insurance)

Relation to the insured (Secondary Insurance)

Insured's Date of Birth (Secondary Insurance)

Insured's Employer (Secondary Insurance)

EMERGENCY CONTACT

Emergency Contact Mobile Phone #

Emergency Contact Relation

Who Is Your Medical Doctor

Medical Doctor's Phone #

Medical Doctor's address

Person responsible for the account

Relation

Billing Address (Street #, City, State, ZIP)

SS#

Driver's Lic.

Work phone #

Payment Method






Authorization



Signature name (Last, first MI)

Electronic signature


Signature Date :

Enter the numbers from the image:



          
562-247-4683
541 W. Willow St, Long Beach, CA, 90806, United States
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