Many dental insurance plans allow us to submit claims electronically on your behalf. In order to do this, we require your authorization. I authorize the release of information contained in claims submitted electronically to my dental benefits provider. I authorize the communication of information related to dental coverage and benefits to my dental insurance provider. If allowed, I also assign my benefits payable from claims submitted electronically and authorize payment directly to this dental practice.
Signature of patient or parent/guardian of minor
MEDICAL HISTORY
Please check the box if you presently have or ever had any of the following:
DENTAL HISTORY
Please check the box if you presently have or ever had any of the following:
Have you ever had:
Do you experience any of the following problems in your jaw:
Additional comments or concerns?
Patient/Guardian signature
WE WOULD LOVE TO GET TO KNOW YOU!
These questions are optional but we appreciate you sharing.
Why did you leave your last dentist:
Is there anything you would like us to know?