All fields marked with an
*
are required fields and must be filled out.
Responsible Party Information
*
Patient First Name:
Patient Middle Initial:
*
Patient Last Name:
*
Responsible Party First Name:
Responsible Party Middle Initial:
*
Responsible Party Last Name:
*
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
If other relationship, please explain:
*
Address:
*
City:
*
State:
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone #:
Insurance Information
*
Is this new insurance or updated insurance?
New
Updated
If updated insurance, effective date:
Primary Insurance
*
Dental Insurance Company Name:
*
Dental Insurance Customer Service Phone Number:
*
Claims Address/PO Box:
*
City:
*
State:
*
Zip:
*
Subscriber First Name:
*
Last Name:
*
Employer:
*
Subscriber ID #: (if Metlife, use SS #)
*
Group #:
*
Subscriber DOB:
*
Subscriber Gender:
Male
Female
Other
Do you have Secondary Insurance
Yes
No
*
Dental Insurance Company Name:
*
Dental Insurance Customer Service Phone Number:
*
Claims Address/PO Box:
*
City:
*
State:
*
Zip:
*
Subscriber First Name:
*
Last Name:
*
Employer:
*
Subscriber ID #: (if Metlife, use SS #:)
*
Group #:
*
Subscriber DOB:
*
Subscriber Gender:
Male
Female
Other