Rogergilbertdds- New patient

Roger N. Gilbert, DDS, Inc.
25875 Barton Road, Suite 104
Loma Linda, CA 92354
Patient Information
Date

MonthDayYear
Patient’s Name

First NameMiddle NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Date
Social Security #
Home Phone
Cell phone
EMail Address
example@example.com
Who may we thank for referring you to our office?
Responsible Party Information

(if someone other than patient)
Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Home Phone
Cell phone
Relationship to Patient
Insurance Information
Name of Primary Insured
Insured Birth Date

MonthDayYear
Insured Social Security # or Alternate ID #
Name of Insurance Company
Employer
Name of Primary Insured
Insured Birth Date

MonthDayYear
Insured Social Security # or Alternate ID #
Name of Insurance Company
Employer
To Change or Cancel an Appointment
We ask that you please notify us at least 48 hours in advance to change or
cancel an appointment or a $50 charge will be assessed to your account.

Acknowledgement of Receipt of HIPAA Notice of Privacy Practices

We at Roger N. Gilbert DDS Inc. are required by federal law to maintain the privacy and provide individuals with a Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with either of our HIPPA Compliance Officers in person or by phone. If you would like a copy, please let our front desk know.
I
understand the aforementioned information and have received or declined a copy of Roger N. Gilbert DDS Inc.’s HIPPA Notice of Privacy Practices.
Name (Patient or Representative)
Signature

Clear
Date

MonthDayYear
If Personal Representative’s signature appears above, please describe Personal Representative’s relationship to the patient