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BILLING INFORMATION
PLEASE PROVIDE DETAILED INFORMATION
Parent/Guardian
First Name
Last Name
Gender
Date Of Birth
Email
Phone
Address
City
State
Zip Code
SSN
Employer
Parent/Guardian
First Name
Last Name
Gender
Date Of Birth
Email
Phone
Address
City
State
Zip Code
SSN
Employer
Dental Insurance
Relationship to child
Gender
Policy Holder First Name
Policy Holder Last Name
Date Of Birth
Insurance Co.Name
Policy ID#
Self-Pay
Responsible Party
INSURANCE CONSENT:
I authorize the insurance company indicated to pay to the dentist all insurance benefits. Any payments received by the doctor from my insurance coverage will be credited to my account. I authorize the use of this signature on all insurance submissions.
Patient/Legal Guardian Signature
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