The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form.
Do you have or have you ever had any of the following? Please check those that apply.
Reason for today's visit:
We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient’s responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to paid for at each visit as they are performed.
Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A fee may be charged for cancelled or missed appointments without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient’s responsibility.