Patient Information

"*" indicates required fields

Patient's Name*







Dated*







Date of Birth:*







Gender*





If child, parent's name







Address










Is it ok to contact you via text





Is it ok to contact you via Email





Address









Address









DENTAL INSURANCE-PRIMARY COVERAGE

Employee's Name



Date of Birth:*







Address









DENTAL INSURANCE-SECONDARY COVERAGE

Employee's Name



Date of Birth:*







Address









Release

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information
concerning my (or my child) health care, advice and treatment provided for the purpose of evaluating and administering claims for benefits. I authorize
release of any information concerning my or my child’s health-care, advice and treatment to another dentist. I hereby authorize payment of insurance
benefits directly to the dentist of the dental groups, otherwise payable to me. I understand that my dental care insurance carrier or payer of dental benefits
may pay less then the actual bill for services. I understand that I am financially responsible for payments in full on all accounts. By signing this statement,
I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payer
The parent or guardian who accompanies the child is responsible for payment.
I attest to the accuracy of the information on this page.

Dated*







This field is for validation purposes and should be left unchanged.