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BILLING INFORMATION
PLEASE PROVIDE DETAILED INFORMATION
Parent/Guardian
First Name
Last Name
Email
Date Of Birth
Phone
Address
City
State
Zip Code
SSN
Employer
Parent/Guardian
First Name
Last Name
Email
Date Of Birth
Phone
Address
City
State
Zip Code
SSN
Employer
Dental Insurance
Responsible Party
Insurance Co.Name
Relationship to child
Self-Pay
Policy Holder First Name
Policy Holder Last Name
Date Of Birth
Policy ID#
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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Signature Pad
Date
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