Insurance Form

General Information

Patient Name

Date of Birth

Primary Dental Insurance

Policy Holder

Self

Other

Policy Holder Name (if not patient)

Relationship to Patient

Self

Spouse

Parent

Legal Guardian

Partner

Other

If other, please specify

Name of Employer

Work Phone

Address of Employer

City

State

Zip

Policy Holder Date of Birth

Insurance Company

Mailing Address of Insurance Company

Insurance Group #

Insurance Plan #

Effective Date

Secondary Dental Insurance

Policy Holder

Self

Other

Policy Holder Name (if not patient)

Relationship to Patient

Self

Spouse

Parent

Legal Guardian

Partner

Other

If other, please specify

Name of Employer

Work Phone

Address of Employer

City

State

Zip

Policy Holder Date of Birth

Insurance Company

Insurance Group #

Insurance Plan #

Effective Date

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Initial

I give my consent for examination and treatment.

Initial

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information may be released to

Spouse

Family

Friend

Other Treating Physician(s)

Do Not Release my Medical Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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