New Patient Information

New Patient Information

PRIMARY INSURANCE

Person Responsible for Account

ADDITIONAL INSURANCE

DENTAL HISTORY

Select one option if you had problems with any of the following:

MEDICAL HISTORY

AUTHORIZATION

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status,I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. authorize the use of this signature on all insurance submissions

I authorize the dentist to release allinformation necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whelher or not paid by insurance.