Patient Information Form

Please correct the errors described below.

Patient Information


Referral Information

Health Information

Have you ever had any of the following?

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail.

Employment Information (Required)


Insurance Information (Required)

Responsible Party Information (Required)(Person Responsible for Payment)



I authorize the Dentist or designated staff treating me to perform such diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize the Dentist to perform all recommended treatment and therapeutic procedures to include administering medications as prescribed by the Dentist and mutually agreed upon by me.

I assign all dental insurance benefits to which I am entitled to the extent permitted under my dental insurance policy(s) to the Dentist. This form also authorizes this Practice to submit insurance claim forms and receive payment directly from the Insurance Carrier with the notation “SIGNATURE ON FILE”. I authorize my Dentist to release treatment records/x-rays or any other information deemed pertinent to my insurance carrier as necessary and/or requested.

I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree that any unpaid claims the carrier does not pay or any balance that extends beyond 45 days from the date of treatment might be assessed to a service charge and/or turned over to a collection agency. I am aware that if my account is turned over to a collection agency, I will be responsible to pay 25% collection agency fees and/or $50.00 court costs or attorney fees.

I have read the above conditions of treatment and payment and agree to their content.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

The interested parties may revoke this authorization in writing only.
Please note once records are established there is a $35.00 charge for duplication of records including x-rays.
Charges will apply for missed or canceled appointments without proper notification.

Your information will be encrypted.