Adult Patient Form

Adult Patient Information

Person Responsible for Account

Dental Insurance Information

Primary Insurance

Secondary Insurance

Medical History

Dental History

Authorization

By clicking Submit, I affirm that the information given is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

By clicking Submit, I also authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. I also authorize release of any information necessary to process dental insurance. I understand that I am responsible for any portion my insurance carrier does not pay.