If Patient is a Child or Dependent, Names and Addresses of Parents or Guardians:
RESPONSIBLE PARTY, IF OTHER THAN PATIENT (financial)
PRIMARY DENTAL INSURANCE (if any)
Please provide us with your insurance card for scanning
SECONDARY INSURANCE (if any)
Please provide us with your insurance card for scanning.
I certify that the information above is true and correct to the best of my knowledge and belief. I authorize my insurance company to pay directly to the dentist’s office, insurance benefits otherwise payable to me. I understand I am responsible for all co-pays, deductibles, co-insurance balances. I understand and agree that my bill for services rendered is due and payable at the time of service and that I am ultimately responsible for any unpaid balances.
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.
We truly appreciate referrals to our practice. Is there anyone we might thank for referring you to our office?
If there is anything we can do to make your visits more comfortable, please do not hesitate to tell us. Thank you for choosing our office!
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