PATIENT FORMS




For your convenience, we've provided patient forms on our website. To help expedite your first visit, please complete all three forms online (by scrolling down).  If you have any questions, please contact us. We are happy to help!

patient forms






All boxes in the following form highlighted in red are required:

Patient Information / Medical & Dental / Insurance Form

Personal Information

Dental Health

Medical History

For Women

Medical Checklist

Primary Physician

Specialist Name (Cardiologist, Surgeon, Internist, etc)

Insurance Information Form - Insured Parties Information

Primary Dental Insurance

Acknowledgement of Receipt of Notice of Privacy Practice / You may refuse to sign this acknowledgement

I authorize & request my insurance company to pay Dental Care, LLC. directly, otherwise payable to me. I unconditionally agree to be responsible for and to pay Dental Care, LLC. for any & all charges incurred. I agree & understand that in the event I do not pay the balance due and my account is placed in the hands of a collection agency &/or Attorney for collection proceedings, I will be legally responsible for all Attorney fees, court costs, collection costs, consideration for assignment, litigation expenses, as well as any other incidental expenses incurred by Dental Care, LLC. &/or their assignees. I further understand a 1 1/2% finance charge (18% annually) for any balance over 90 days. ___________________________________________________________________________________

Form Validation