CCS Secure File Upload

Please upload a copy of the patient's referral form, medical and dental insurance cards (front & back), medical clearance forms (if requested), and a copy of the guardian's photo ID.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Notes (optional)
File Uploader:

Please upload any files you would like to send Dental Surgery Center of DC here (including photos uploaded from your mobile phone).
Cancelof
1. To maintain your privacy, all files are securely transferred to Dental Surgery Center of DC.
Should be Empty: