Randy T. Lee, DDS
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Patient Name: _______________________________________________
                                            First              Middle                 Last

Address: ___________________________________________________
                                             Street                  Apt #

City, State, Zip Code: ____________________________________________

Home Phone #: ________________________Birthdate: ______________

Driver License #: _________________State_____Social Security #: _____________

EMail Address: ________________________________ Sex: Male___ Female___

Nearest friend/relative (not living with patient): ___________________________________
                                                                                          Name Relationship Telephone #

How did you find us? ___________________________________________________

Patient Occupation/Job Title: ______________Work Phone #: ___________

Patient’s Employer: _______________________________________________

Employer Address: _________________________________________________
                                                   Street           Apt #              City             State                Zip Code

Spouse’s Name: _________________________________________
                                           First             Middle              Last

Spouse’s Occupation/ Job Title: ____________ Work Phone #: _________

Spouse’s Employer: ____________________________________________________

Employer Address: ______________________________________________________
                                                      Street             Apt #           City        State               Zip Code

Primary Insurance Company/Program: ______________________________________


Insurance Phone #: ____________________Group #_________ Subscriber #: _________

Insured Name: ______________________Relationship to Patient___________


Secondary Insurance Company/Program: _____________________________________


Insurance Phone #: _______________Group #________ Subscriber #: __________

Insured Name: _______________________Relationship to Patient__________


Assignment and Release:

I, the undersigned, have insurance coverage with___________________________________
                                                                                                 Name of Insurance Company
and assign directly to Dr. Randy Lee all dental benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

Signature of Insured/Guardian_______________________Date:____________