Sample Page

Thank you for filling out this form completely. The information you provide will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask – we are always happy to help.

    Personal Information
    1. MondayTuesdayWednesdayThursdayFriday
    2. MondayTuesdayWednesdayThursdayFriday
    3. MaleFemale
    4. MinorSingleMarriedDivorcedWidowedSeparated
    In Case of Emergency
    Responsible Party

    * Required

    Primary Dental Insurance Information
    Additional Dental Insurance
    Authorization and Release
    1. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or other health practicioners.
    2. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.
    3. I understand that my dental insurance carrier may pass less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
    Financial Arrangements
    1. CashPersonal CheckCredit Card (Visa)Credit Card (MC)I wish to discuss the dental office's policy.

    Late Charges

    If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.