New Patient Form

Please correct the errors described below.

Patient Information

Dental Insurance

Assignment and Release

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services, This consent will end when my current treatment plan is completed or one year from the date signed below.

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

Phone Numbers

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

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Dental History

Please choose on "Yes or No" to indicate if you had any of the following:

Health History

Please choose on "Yes or No" to indicate if you had any of the following:

For Women Only:

Medications

Allergies

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