Coronavirus (COVID-19) update: We will continue to provide essential and emergent care for patients who need emergency dental care or are in pain at offices that remain open. Please call to schedule an appointment.

Patient Information Form (Test Page)

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Responsible Party Information

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • 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's) healthcare, advice and treatment provided for the purpose of administering claims for insurance benefits. I authorize release of any information concerning my (or my child's) healthcare, advice and treatment to another health care professional. I hereby authorize payment of insurance directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand that I am financially responsible for payment in full of all accounts. By signing this agreement, 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 payor. I understand that fees for professional services are due at time of service. I understand that account balances over 60 days past due are subject to a monthly rebilling fee. I understand that 48 hours notice is required when canceling/changing an appointment. I understand that there may be a $50 fee incurred for broken appointments. I attest to the accuracy of the information on this page.

  • Medical History

  • Date Format: MM slash DD slash YYYY
  • Do You Now, Or Have You Ever Had, Any of the Conditions Listed

  • Date Format: MM slash DD slash YYYY

 

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