Welcome
Patient Information
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Married
Widowed
Single
Minor
Seperated
Divorced
Partnered for
Dental Insurance
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ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to
Dr. 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 doctor may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or benefits payable for related services. This consent will end when my current treatment plan is completed or one year from th date signed below.
Phone Numbers
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)
Dental History
Please select "Yes" or "No" to indicate if you have had any of the following:
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Yes No
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Yes No
Yes No
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Yes No
Yes No
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Yes No