PERSONAL INFORMATION















    WE CAN BILL YOUR INSURANCE COMPANY DIRECTLY IF YOU CAN PROVIDE US WITH YOUR INSURANCE CARD. PLEASE PRESENT IT WITH THIS FORM FOR US TO COPY

    INSURANCE: In order to prevent any misunderstanding about your dental insurance, please note that all professional services provided are the financial responsibility of the patient or legal guardian. Full payment is due when services are rendered unless financial arrangements are made ahead of time. With your permission, we can contact your insurance provider on your behalf to determine eligibility and benefits.

    APPOINTMENTS: Appointment times are reserved for you. If you are unable to keep an appointment please allow two business days notice to avoid a late-cancellation or missed appointment fee ($100/hour)

    PERMISSION TO TREAT: This is to certify that I, the undersigned, consent to the performing of dental and oral surgery procedures that are necessary or advisable, including the use of local anesthesia. I authorize the release of any records that are relevant to the processing and payment of this claim held by the service provider, any appropriate health professional licensing or regulatory body for the purpose of administrative audit.







    DENTAL HISTORY AND INFORMATION









    MEDICAL INFORMATION











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