Insurance Information

First Name:

Last Name:

Birthdate:

Do you have dental insurance? No Yes, and I can provide my insurance information below Yes, but I don't have my insurance information

Your consultation is complimentary. We have found that our patients and parents want the convenience of getting as much information at the first visit as possible. If you provide us with your insurance information PRIOR to your appointment, we will be able to find out about your insurance benefit and factor that into any treatment fee proposal. If you have dental insurance and do not provide us with that information prior to your appointment, we will not be able to present you with a fee at your consultation.

Primary Insurance

Policy Holder’s Name:

Policy Holder’s Date of Birth:

Employer Name

Insurance Company Name:

Policy #:

Group #:

Employer ID# or Social Security #:

Secondary Insurance

Policy Holder’s Name:

Policy Holder’s Date of Birth:

Employer Name

Insurance Company Name:

Policy #:

Group #:

Employer ID# or Social Security #: