Kids Dentist Beverly Hills dental appointments West la
3909 S. Sepulveda Blvd.
Culver City, CA 90230
(310) 390-6000
info@beverlyhillskidsdentist.com
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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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  Copyright 2008-2009. United Dental Care, Inc. All Rights Reserved  
       
United Dental Care is a full service dental office meeting dental needs for patients based out of California. The services we offer include services such as teeth whitening and gum cleaning. We provide dental services for Kids, Infants, and Adults We serve patients in California including: West Wood Village, Rancho Park, West Hollywood ,Beverly Hills, Culver City, Palms, Mar vista, Playa vista, Marina del rey, Playa del rey, West la, Inglewood, Santa Monica, Venice, Baldwin Hills,West wood, Century City, and Los Angeles.
 
 

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