Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.
All of this information is completely confidential.
Responsible Party Information
Dental Insurance Information
INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT
Dental History (New Patients Only)
I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.