Medical History

Personal Information
Name*
First Last
Nickname
Gender*
Marital Status*
Birth Date*
Occupation*
Email*
Cell Phone*
Address*
Street Address Address Line 2 City State Zip/ Postal Code
Who may we thank for your referral?*

Primary Insurance
Insurance*
- I will not be using / or have any dental insurance.
- I will be using my dental insurance.
Important Dental Insurance Information
We are pleased to inform our patients we accept insurance benefits from most dental carriers. As a courtesy to you we will file dental claims on your behalf and allow 30 days for your insurance policy to reimburse our office for treatment. Unpaid claims after 30 days for any reason will default to the patient’s responsibility. Any procedures not covered by insurance will require full payment at time of service. Please be mindful you are fully responsible for all fees associated with treatment provided regardless of your insurance decision to provide coverage. In the event that insurance has paid less than we had anticipated, you will receive a notification of any remaining balance which will be due upon receipt. Any overdue balances that are carried over may constitute a 15% re-occurring monthly interest fee.
Insured Name*
First Last
Insured's ID*
Insurance company name*
Insurance Company Address
Street Address Address Line 2 City State Zip/ Postal Code
Insurance Company Phone #*
Name of Insured's Employer*
Relationship to patient*
Insured's Date of Birth*
Group #*

Patient Agreement
We encourage any patient utilizing dental coverage to understand the limitations within your dental policy. We make every effort to provide the most accurate estimates for cost of treatment based on the information proved by your insurance company. Should questions arsie, it is best to contact your insurance company directly. While we estimate your dental benefits to the best of our ability, this is an ESTIMATE ONLY, and should not be depended on as a final decision. All applicable payment for services will be due at the time of scheduling.

Payments Options
For your convenience we accept payment in forms of cash, check, all major credit cards as well as no interest financing through CareCredit.
**CareCredit may be applied for prior to your appointment online at www.carecredit.com.
Any checks returned unpaid by your bank will be charged a $30.00 returned check fee and future payments will only be accepted in forms of cash or credit.

Copays and Estimates
We make every effort to provide the most accurate estimates for cost of treatment based on the information provided by your insurance company. All applicable payment for services will be collected at the time of your visit. While we will estimate your dental benefits to the best of our ability, this is an estimate ONLY, and should not be depended on as the final decision. Should questions arise, it is best to contact your insurance company directly. We encourage any patient utilizing dental coverage to understand the limitations within your dental policy.
Payment*
- I prefer to pay my copays at the time of scheduling
- I prefer to pay for services in full at the time of scheduling and be reimbursed by my insurance carrier

Authorization for Release of Health Records to External Parties (optional)
I authorize the disclosure of information from my treatment records to:
- Yes
Name of Recipient
Relationship to Patient
I give authorization to disclose the following information
- All Treatment information
- Information specifically related to these treatment dates
Starting Date
End Date
Appointments
We will always respect your time, and our team will make every effort to schedule appointments that accommodate the needs of all of our patients. In return, we ask that our patients make every effort to keep their reserved dental appointments.
As a courtesy you will receive verification of your appointment via text and email beginning 2 weeks prior to your appointment. We understand emergencies may arise and personal schedules may have unforeseen changes that prevent patients to keep their planned appointments. In the event you should need to reschedule an appointment, we ask for the consideration of a 48 hour notice. If an appointment is broken or an appointment is missed, it creates scheduling challenges for other patients as well as for our office.
** Repeated cancellations without adequate advanced notice will be subject to a non-refundable $50.00 broken appointment fee. For any further missed or broken appointments, our office reserves the right to dismiss a patient from the practice.
Privacy Policy*
- I have read and understood the Privacy Policy
Please Initial Here*

Schedule
appointment

Request
callback

Step 1 of 6

Personal Information

Dental History

Medical History

Women

Primary Insurance

Important Dental Insurance Information

Patient Agreement

Payments Options

Copays and Estimates

Authorization for Release of Health Records to External Parties (optional)

Appointments

Ready for Great Dentistry!

Schedule appointment

Request callback

Medical History

Step 1 of 6

Personal Information

Dental History

Medical History

Women

Primary Insurance

Important Dental Insurance Information

Patient Agreement

Payments Options

Copays and Estimates

Authorization for Release of Health Records to External Parties (optional)

Appointments

Ready for Great Dentistry!

Schedule
appointment

Request
callback