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Patient Form

Welcome

Thank you for selecting Dental On First!
We will strive to provide you with the best possible dental care.  To help us meet your dental healthcare needs, please fill out this form completely in ink.  If you have any questions or need assistance, please ask us – we will be happy to help

We offer a 5% discount on payment in full for same day services.

Please download, and print, our Patient Registration form. Fill it out, and bring with you to your appointment.

NEW PATIENT REGISTRATION FORM

Patient Information

Responsible Party

Insurance Information

DO YOU HAVE ADDITIONAL INSURANCE? IF YES, COMPLETE THE FOLLOWING:

Patient Medical History

7. Do you have or have you had any of the following?

Patient Dental History

7. Have you ever experienced any of the following problem in your jaw?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be harmful to my health. I authorize the dentist to release any information rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.