Madderra Dental Spa

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Patient Intake Submissions

3 total submissions

Stephen Gardner
Submitted: 2/28/2026DOB: 1976-09-26
submitted

Contact Information

[email protected]

5853625988

3624 Soothing Surf Drive, Las vegas, NV 89147

Medical History

Conditions:
  • None
Allergies:
  • None

Insurance

Provider: Delta Dental

Policy #: 1234567

Group #: 123456

Emergency Contact

Name: Joe Smith

Phone: 123-456-7890

Relationship: mother

Dental Concerns

None

Consent & Authorization

Treatment Consent: yesHIPAA: yesFinancial Policy: yes
John Doe
Submitted: 2/28/2026DOB: 1985-05-15
submitted

Contact Information

[email protected]

4155551234

123 Castro St, San Francisco, CA 94114

Medical History

Conditions:
  • Diabetes
  • High Blood Pressure
Allergies:
  • Penicillin

Insurance

Provider: Delta Dental

Policy #: DD123456

Group #: GRP789

Emergency Contact

Name: Jane Doe

Phone: 4155555678

Relationship: Spouse

Dental Concerns

Tooth sensitivity and whitening

Consent & Authorization

Treatment Consent: yesHIPAA: yesFinancial Policy: yes
John Doe
Submitted: 2/4/2026DOB: 1985-05-15
submitted

Contact Information

[email protected]

4155551234

123 Castro St, San Francisco, CA 94114

Medical History

Conditions:
  • Diabetes
  • High Blood Pressure
Allergies:
  • Penicillin

Insurance

Provider: Delta Dental

Policy #: DD123456

Group #: GRP789

Emergency Contact

Name: Jane Doe

Phone: 4155555678

Relationship: Spouse

Dental Concerns

Tooth sensitivity and whitening

Consent & Authorization

Treatment Consent: yesHIPAA: yesFinancial Policy: yes