Patient Information Form

Please correct the errors described below.

If patient is a child, give name of Parent or Legal Guardian:

Dental Insurance

Financial Agreement

Please read carefully; initial next to each line.

DISCLAIMER: 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.

(If for a child, financially responsible, adult must sign.)

Your message will be encrypted.