Responsible Party (if different from above)
As a courtesy we will submit services rendered to your insurance carrier. Your portion is due in full at time of service. I understand that my dental insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services rendered on my behalf or my dependents. If you wish to discuss the office's payment policy, please ask us and we will be happy to help.
Dental Insurance Information
Do You Have any Additional Dental Insurance? (If yes, then complete the following)
Medical Insurance Information
Do You Have any Additional Medical Insurance? (If yes, then complete the following)
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Please answer the following questions.