PATIENT REGISTRATION ID: Chart ID: First Name: Last Name: Middle Initial: Patient Is: Preferred Name: Patient Information Primary Insurance Information Address: Address 2: City: Zip code: Home Phone: Work Phone: Ext: Cell: Sex: Marital Status: Birth Date: Age: Soc. Sec. Drivers Lic: E-mail: Employment Status: Ocupation: Employer : Referring Dentist: Pref. Hygienist: Pref. Pharmacy: Name of Insured: Relationship to Insured: Insured Soc. Sec.: Insured Birth Date: Employer: Ins. Co.: Address: Address: Address 2: Address 2: City, State, Zip: City, State, Zip: Rem. Benefits: .00 Rem. Deduct.: .00 Responsible Party (if someone other than the patient) First Name: Last Name: Middle Initial: Address: Address 2: City, State, Zip: Email: Home Phone: Work Phone: Ext: Cell: Birth Date: Soc. Sec. Drivers Lic: Policy Holder Responsible Party Female Male Married Single Divorced Separated Widowed Full-time Par-time Retired State: Responsible Party is also a policy holder for patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Self Spouse Child Other Secondary Insurance Information Name of Insured: Relationship to Insured: Insured Soc. Sec.: Insured Birth Date: Employer: Ins. Co.: Address: Address: Address 2: Address 2: City, State, Zip: City, State, Zip: Rem. Benefits: .00 Rem. Deduct.: .00 Self Spouse Child Other Comments: Rodica S. Grasu, DDS, MS Periodontics and Implant Surgery 16055 Ventura Blvd. Suite 405, Encino, CA 91436 Phone (818) 990-5090 Fax (818) 990-5098