New Patient Form

  • Patient Information

  • Phone Numbers

  • Dental Insurance

  • Assignment and Release
    I certify that I, and/or my dependent(s), have insurance coverage and assign directly all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
    The dentist may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
  • Dental History

  • Health History

  • Signature