Dental Patient Information Form | Dentists Services Culver City

3909 S. Sepulveda Blvd. Culver City, CA 90230
info@losangeleskidsdentist.com

PATIENT INFORMATION

First Name*		MiddleInitial*

Last Name*		Nick Name*

Address*		City

State		Zip

Employer		Date of Birth

Drivers Licence		Email*

Height		Weight

Home Phone		Work Phone

Cell Phone

Sex: Male Female

Social Security #		Emergency: Name		Phone

May we contact you at work?: Yes No

INSURANCE

Primary Dental Carrier

Subscriber Name		Social Security #

DOB

Employer		Insurance Co.		Insurance Co. Phone #

Group #		Relation to patient

Secondary Dental Carrier

Subscriber Name		Social Security #

DOB

Employer		Insurance Co.		Insurance Co. Phone #

Group #		Relation to patient

I hereby authorize payment directly to the United Dental Care of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I hereby authorize the United Dental Care Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical history is correct to the best of my knowledge.

If Patient is Under 18

Responsible Party*		Relation to Patient*

Address*

City		State		Zip

Phone No *

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United Dental Care offers dental services for patients based out of California. We offer services such as Kids dentistry, Adult dentistry and Baby dentistry. We also provide services such as teeth and gum cleaning. We serve patients in California including: Culver city, Rancho park, Palms, Mar vista, Playa vista, Marina del rey, Playa del rey, West la, Inglewood, Santa Monica, Venice, West wood, West wood village, Beverly hills, Century city, West Hollywood, Baldwin hills and Los Angeles.