Patient information form – new

Once you have booked an inital consultation please fill out this form prior to your appointment, or if your perfer download the form and print it off. Please contact our office if you require assistance.

ACCOUNT INFORMATION: Person responsible for Account (Parent/Guardian if patient is a minor)

DENTAL INSURANCE

We do not bill dental insurance companies directly. Payment from the responsible party is required at the time the service is provided. We will aid you with preparing your insurance claims so that you may receive reimbursement directly from your insurance company.

Does the patient have a history of any of the following?

ANY INFORMATION PROVIDED WILL BE HELD IN STRICTEST CONFIDENCE.
PLEASE INFORM THE OFFICE IF ANY OF THE ABOVE INFORMATION CHANGES DURING THE COURSE OF TREATMENT.