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PATIENT INFORMATION

INSURANCE INFORMATION

Primary Dental Insurance

Secondary Dental Insurance

MEDICAL HISTORY

HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING? Check YES OR NO

Please List Known Allergies To Any Of The Following:

For Women:

As the patient (or legal guardian) you are responsible for full payment of any services received on the day of service regardless of insurance coverage. We DO NOT accept payment from insurance companies. Full payment must be made to our office by the patient or guardian. Any insurance reimbursement will go directly to the plan holder.

ELECTRONIC INSURANCE CLAIM SUBMISSION CONSENT

I authorize the release of information to my dental benefits plan administrator and the Canadian Dental association information contained in claims submitted (electonically). I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.