Client Information

Welcome! Thank you for selecting our dental health care team! We will do all we can to provide you the best possible oral health care. To help us meet your dental needs, please complete this online form. If you have any questions or need assistance, just ask. We will be happy to help.

Personal Information

Full Name(Last, First, Middle Initial):

Email Address:

Home address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Employer:

Referred by:

Date of birth:


Insurance Information

Subscriber's employer:

Full Name(Last, First, Middle Initial):

Date of birth:

Plan name:

Plan phone number:

Group number:


Subscriber's #2 Employer:

Full Name(Last, First, Middle Initial):

Date of birth:

Plan name:

Plan phone number:

Group number:


In case of emergency, please notify

Name:

Relationship:

Telephone:

Physician:

Physician's phone number:


Verification Code
(case sensitive):


Authorization and Release

I authorize the dentist to release any information, including the diagnosis and records of any treatment or examination rendered to me during the period of such dental care, to third-party payors and/or other health practitioners.

I authorize and request my insurance company to pay directly to the dentist or dental group, the insurance benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than the total bill for services. I understand that I am responsible for payment of all services rendered on my behalf or that of my dependents.