Retainer Fitting Form - USA 🇺🇸

1

Name* This field is required.

First Name

Last Name

2

Birthdate* This field is required.

Date

3

Email* This field is required.we will send you instructions

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Product purchased* This field is required.What did you order?

Clear Aligners

Retainers

Night Guard

6

Insurance Provider* This field is required.

7

Insurance Member ID* This field is required.

8

Group Number* This field is required.

9

Are you the primary account holder?* This field is required.i.e. is the insurance coverage under your name?

Yes

No

10

Primary account holder name* This field is required.

First Name

Last Name

11

Primary account holder date of birth* This field is required.

Date

12

Customer’s relationship to primary account holder* This field is required.

Spouse

Dependent

Other

13

Employer Name* This field is required.If your insurance is employer-provided

14

Do you have an HSA/FSA card?* This field is required.

Yes

No

15

Please enter your card details* This field is required.

Please enter your card number

16

Insurance card* This field is required.Upload a photo of the FRONT of your card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

Insurance card* This field is required.Upload a photo of the BACK of your card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

18

Insurance Phone Number * This field is required.Found on the back of your card

Please enter a valid phone number.

19

Purchase Date* This field is required.

Date

20

Insurance Claim FormForm used to claim benefits with your provider.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

21

Signature* This field is required.I authorize NewSmile to contact my insurance provider to verify coverage and benefits for orthodontic treatment.

Clear