Patient Information Form

Welcome to our Practice! We look forward to providing you with the highest quality dental care! The following is a state of our office policy and financial policy which we ask that you read, agree to, and sign before any treatment is rendered.
  • Contact Information

  • Insurance Information

    All information applies to subscriber
  • Our office will gladly submit your insurance claim to your insurance carrier, as a courtesy to you. At the time of treatment the patient is responsible for the portion the insurance does not cover. Please be aware that some insurance companies may not cover all services performed in our office. The patient is responsible for all charges that are denied or unpaid by your insurance carrier. Most dental insurances have limits and/or various degrees of co-payments.
  • Payment Terms

  • Cancellation Policy

  • Protected Health Information

  • Please distinguish any person/persons to whom you authorize Devine Dentistry to release your protected health information. Please be specific.
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  • NameRelationship 
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  • Referrals

  • This field is for validation purposes and should be left unchanged.