Dr. Marina Alvarez-Pettengill, DDS
 The benefits of a happy, healthy smile are immeasurable. Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we can communicate, the better we can care for you and your child. Today’s Date: _______________ Name: ______________________________________________________ Last Name, First Name, Middle Initial I prefer to be called: ___________________________ ( ) Male ( ) Female Birth Date: _____________ Age: ______ SS#: _______-______-________ Home Address: _______________________________________________ ____________________________________________________________ City, State, ZIP Code Home Telephone: ______________ Work/Other: __________________ Where and when is the best time to reach you? _______________________________________________________ Whom may we thank for referring you? ____________________________ Other family members seen by us: ________________________________ Previous/Present Dentist: ______________________________________ Date of Last Dental Visit: _______________________________________ In the event of an emergency, is there someone who lives near you that we may contact? Name: ____________________________ Relationship: _______ Home Telephone: ______________ Work: _____________ Person Responsible for Account: _________________________ Telephone: ____________________ Work: ______ Extension: ________ Billing Address: _____________________________________________ Relationship to Patient: _________________SS#: _______-______-________ Employer: __________________________________________________ Primary Dental Insurance Insurance Company: _________________ Telephone #: _______________ Insurance Company Address: _________________________________ Group Number: ___________ Policy Number: ___________________ Insured's Name: ___________________ Relationship: _____________ Insured's Date of Birth: _______ Insured's SS#: _____-____-_______ Insured's Employer: ________________________________________ Employer's Address: ________________________________________ Secondary Dental Insurance To minimize out-of-pocket payments, please provide secondary insurance company information. Insurance Company: ________________ Telephone#: ____________________ Insured's Name: __________________________________________ Insured's Date of Birth: _______ Insured's SS#: _______-______-________ Employer Name: ____________________________________________ |
For questions, email us at drmarina@naisp.net
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Phone: 508-699-2221 Fax: 508-699-2910 Hours: Address: 74 Taunton Street Suite 101 Plainville, MA 02762 (We are located in the Shepardville Professional Park on Route 152, near Route 1 and I-495 in Plainville) |