New Patient Forms

Patient Information

Phone Numbers

Dental Insurance

Dental History

Have you had any of the following?

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage and assign directly to the dentist all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize use of my signature on all insurance submissions. The dentist may release my health care information to my insurance company to determine benefits payable for related services.

Patient

General Health

Health problems you may have, or medication you may be taking, could affect the dentistry you receive. Thank you for answering these questions.

Women

Allergies

Do you have, or have you had, any of the following?

Other

Signature

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.