New Patient Form

PATIENT INFORMATION:

SexMaleFemale

MEDICAL HISTORY

Do you use chewing tobacco?YesNo

above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.

DENTAL INSURANCE INFORMATION: Our office is “fee for service”, which means we collect all fees at the time of service. However, if you do have dental insurance we want to help you receive your benefits. We can do that by collecting your insurance information, filing your claim electronically, and having the payment of your benefit sent directly to you. This is typically a fast process—you should hear from your insurance company within 2-3 weeks, although we cannot guarantee what the reimbursement amount will be. We suggest you file a pre-treatment estimate request for all major work if you desire to know your benefit amount in advance. Please provide complete insurance information if you would like us to file claims for you.

AUTHORIZATION:

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

I authorize the dentist to release all information necessary to secure the payment of benefits.

understand that I am financially responsible for all services performed at time of treatment.