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  • General Patient Information

  • Welcome to the office! Please take a few moments to enter the following information so that we may better and more quickly assist you.

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  • Insurance - Primary

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  • Insurance - Secondary

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  • Emergency Contact

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  • Medical History

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  • Assignment and Release

  • I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Studio Smiles all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurances.  I hereby authorize the doctor to release all information necessary to secure the payments of benefits.  I authorize the use of this signature on all insurance submissions.  I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge.  I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

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  • Dental History

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