Dental Insurance Form

To complete this Dental Insurance Form, simply fill out the fields with the requested information. While most of the fields are optional, certain fields marked by asterisks (*) must be completed. Please do not use your browser's Back or Forward buttons. Use of these buttons may “undo”/”redo” recent actions. Once you have completed this document, simply click the submit button to proceed.

If you do not have dental insurance, simply enter your first and last name, check the box "I am the responsible party," and click the submit button to proceed.

Name

First

Middle

Last

Insurance Coverage

I do not have dental insurance.

If patient is the responsible party, please check the box below.

I am the responsible party.

Please provide the following information of responsible party.

Name

First

Middle

Last

Date of Birth

Gender

Male
Female

SSN

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Work Phone

Mobile Phone

Email

Relationship to the Patient

If other, please explain.

Employer Name

Occupation

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer Work Phone

Primary Dental Insurance Information

Insurance Provider

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

ID

Group/Policy

Secondary Dental Insurance Information

Insurance Provider

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

ID

Group/Policy

Signature

Please draw your signature in the box. Use the X to clear your signature.

Please carefully review your information before submitting this document.

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