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Insurance Form

General Information

Primary Dental Insurance

Policy Holder
Relationship to Patient

Secondary Dental Insurance

Policy Holder
Relationship to Patient

I give my consent for examination and treatment.

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information may be released to


NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.