Dr. Sam F. Khoury

3000 Alamo Drive, Suite 206, Vacaville, California 95687

707-451-1311

Patient Information

Patient Name:
Home Address
Apt/Condo #
City
State
Zip
SS#
Student School
Home #
Work #
Cellular
Email
Employer
Marital Status
Sex
Birthdate
Age
Spouse Name
Who May We Thank for Referring You
Employer's Address
How Long There?
Occupation
Best Times to Reach You:

Spouse Information
Name
Employer
Work #:
SS #:
Birthdate
Person Responsible for Account
Name
Billing Address:
City
State
Zip
Relation
SS #
Employer
Work #
Home #

Dental Insurance

Primary Dental Insurance
Insurance Co. Name
Ins. Co. Address
Ins. Co. Phone #
Insured's Name
Relation
Group #
Birthday
SS #
Insured's Employer
Secondary Dental Insurance
Insurance Co. Name
Ins. Co. Address
Ins. Co. Phone #
Insured's Name
Relation
Group #
Birthday
SS #
Insured's Employer
Medical Insurance Carrier
Insured's Employer
Physician's Name

In the event of an emergency, is there someone that we should contact?

Name
Relationship
Wk #:
HM #:

I hereby authorize payment directly to Dr. Khoury of the group insurance benefits otherwise payable to me.

Signed:

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If you have insurance, we will file your forms promptly, and request that you pay your portion when the services are rendered. You are also responsible for any balance not covered by your insurance plan. Please bring your insurance card and forms with you. If you do not have insurance we request payment in full at the time of services unless other arrangements have been made. I have read and understand the above financial information.

Patient or Responsible Party Signature

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Date:

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