Patient Forms Patient Information Choose One: Male Female Date of Birth: Do you have Dental Insurance? Yes No Primary Insurance and/or Person Responsible for Payment Choose One: Hourly Salary Secondary Insurance and/or Spouse I authorize the dentist and dental staff to perform any neccessary dental services that I may need during diagnosis and treatment with my informed consent. INSURANCE COVERAGE IS ONLY AN ESTIMATE. PATIENT OR GUARANTOR IS RESPONSIBLE FOR ALL TREATMENT NOT COVERED BY INSURANCE. Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.