Lutz Patient Forms

Insurance Information
Primary
First Name of Insured
Last Name of Insured
Is Insured a Patient?
Insured Date of Birth
Date Format: MM slash DD slash YYYY
ID Number
Group Number
Insured's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insured's Employer Name
Insured's Employer Address
Street Address City State ZIP Code
Patient's Relationship to Insured
Insurance Plan Name
Insurance Plan Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Secondary
First Name of Insured
Last Name of Insured
Is Insured a Patient?
Insured Date of Birth
Date Format: MM slash DD slash YYYY
ID Number
Group Number
Insured's Address
Street Address City State ZIP Code
Insured's Employer Name
Insured's Employer Address
Street Address City State ZIP Code
Patient's Relationship to Insured
Insurance Plan Name
Insurance Plan Address
Street Address City State ZIP Code

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Name of Patient, Parent, or Guardian
First Last
Signature
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- I understand

Name	Strength	How Often	Purpose of Med

Patient Information