This personal information is requested to enable us to give you the most consideration of your time and feelings. It is important to have complete answers so that we may give you the personal attention you deserve. This information is kept completely confidential.
ARE YOU EXPERIENCING ANY DENTAL PROBLEMS AT THIS TIME? IF SO, WHAT?
To obtain maximum dental benefits for our insured patients, we have our staff specifically trained to do just that. In order get your full complete benefits, we will need the following information:
I hereby authorize and request the performance of dental services for myself by the staff of Rodney G. Sigua, DDS, MAGD, PLLC.
I also give my consent to any advisable and necessary dental procedures, medications or anesthetics to be administered by our staff for diagnostic purposes or dental treatment.
I understand and acknowledge that I am financially responsible for the services rendered, regardless of insurance coverage.
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.
Your information will be encrypted.