Patient Information

Responsible for Payment

(Someone other than patient providing insurance or payments)

Emergency Contact

Employment Information

Authorization and Release

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me, my spouse or my child during the period of such dental care to the third party and/or other health practitioners. 

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. 

I understand that my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. 

**Payment is required in full before any service is rendered, please have payments in full at each appointment.**

Health History 

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 may have, or medications that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Please answer all questions and list any and all medications. 

Dental History 

Medical History 

Please answer the questions below if you will be using insurance with your visit.

If you do not have an insurance card please provide the primary insurance holder's information below: