Let's get you Updated!

This is for our EXISTING patients only

Name *
Name
First & Middle (no comma)
Date of Birth *
Date of Birth
Cell Phone
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Status *
Name, Relationship, Phone
INSURANCE
Policy Holder DOB *
Policy Holder DOB
Who is your provider?
Card Information
Dental Insurance Only
Insurance Company Phone
Insurance Company Phone
Benefits Department # (If listed)
Do you have secondary insurance?
Policy Holder, Policy holder DOB, Policy Holder SSN, Ins Co Name, Group #, ID #, Ins Co Phone #
Physician's Phone
Physician's Phone
Current Health
Are you currently taking any medications?
Women
Are you...
You're almost there, just one last piece
HEALTH HISTORY
Are you allergic to any of the following?
Check all that apply
Wants? Needs? Desires? Interested in Whitening, Alignment, Holistic Services, etc..
It is the responsibility of the patient to provide 24 hours notice of cancellation or re-scheduling of their appointment. Canceling/ re-scheduling your appointment with less than 24 hours will result in a fee of $45/hour scheduled that is missed. Please note that the missed appointment fee is not covered by any insurance provider and is the patients responsibility to pay. PLEASE TYPE INITIALS BELOW AS YOUR ELECTRONIC SIGNATURE