We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health.
(Person Responsible for the Account Fill Out Below)
(If Patient is covered by Additional Insurance, Person Responsible for the Account Fill Out Below.)
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Positive responses to any of thse would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
For testing, see the list of State and Territorial Health Department Websites for your specific area's information.