Online Patient Information Form
I certify that I, and/or my dependent(s), have insurance coverage with
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 above-named dentist may use my health care information and may disclose such information to the
above-named Insurance Company(ees) 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.
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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions pertaining both your dental and medical history.
PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:
DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?