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New Patient Intake Form
Insurance Information
If you are able to, please upload an image of your dental insurance card
Upload or drag files here
Upload or drag files here
If you are able to, please upload an image of your dental insurance card
Upload or drag files here
Upload or drag files here
Assignment and Release:

I assign directly to Dr. Reddish all insurance benefits, if any, otherwise payable to me for services rendered.
I authorize the use of my signature on all insurance submissions.

Signature Pad

Done