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Who will be responsible for your account? (if self is selected, please skip to next section)

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Health History

Have you had or do you currently have the following:


Are you taking any of the following?

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

For Women Only

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

I have read and understand the above. I understand the importance of a truthful and complete Health History to assist in providing the best care possible. I hereby acknowledge that all information above is correct.


Fees and Payments

We make every effort to keep down the cost of your oral surgical care. You can help by paying on completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information at the top of the form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor, and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and other pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. Any account over 90 days will be charged a 1-1/2% finance charge monthly with an annual rate of 18%, in addition to any collection agency fees and/or attorney fees and court costs incurred in the collection of outstanding balances.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the dentist name of the insurance benefits otherwise payable to me.


Click on the hyperlink to obtain a copy:

I hereby acknowledge that I have reviewed a copy of this office's Notice of Privacy Practices. I give my permission to discuss this account to the following:


If Patient is a Minor

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