sunrisemountainomfs.com

Does the patient have dental insurance?
Insurance Holder's Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Employer
Member ID
Group ID
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insured's SSN
Secondary Dental Insurance
Does the patient have additional dental insurance?
Insurance Holder's Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Employer
Member ID
Group ID
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insured's SSN

Signed Consent
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.By submitting this form you agree to the above mentioned consent statement
Signature
Date

MonthDayYear
Date
Should be Empty:

BP E-Form