Financial/Insurance Form

New Patient Financial/Insurance Form

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Tell Us About Your Child/Children

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Parent or Legal Guardian's Information

The information in this section applies to to the main legal caregiver of the child / children.
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Marital Status(Required)

Spouse or Other Legal Guardian's Information

(if different from #2 above)
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Marital Status

How Did You Learn About Our Practice

Who Will Be Accompanying The Child/Children To Their Appointment?

Important Note: The parent or guardian who accompanies the child is legally responsible for payment at the time of service.
Do you have legal custody of the child?(Required)

Person Responsible For Account

Billing Address(Required)

Emergency Contact Information

Primary Dental Insurance

Insurance Address(Required)
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Dual (Secondary) Insurance

Do you have dual (secondary) insurance?
Insurance Address
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HIPAA Consent

I have been informed by your office of your Notice of Privacy Practices with a complete description of the uses and disclosures of my health information. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action on this consent rendered. I have read the above information and understand my obligations.

Financial Policy

Payment is due when services are rendered. We accept cash, personal checks, and all major credit cards. We realize that some procedures are more extensive than others and we will be more than willing to work out alternative financial arrangements prior to treatment. I understand and agree that, (regardless of my insurance status or marital status), I am ultimately responsible for the balance on this account for any professional services.

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes.

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