New Patient Form

Please correct the errors described below.

Patient Information

Dental Insurance

Assignment and Release

all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

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 that does not live in your household)

Dental History

Please Mark "Yes" or "No" to Indicate if you have had any of the Following:

Health History

Please Mark "Yes" or "No" to indicate if you have had any of the following:

Women:

Medications

Pharmacy Information

Allergies

Updates (To be filled out within the office at a future appointment.)

Update #1

Update #2

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