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  • Primary Dental Insurance Information

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  • Subscriber's Signature

  • A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the responsible party. For your convenience, we will gladly assist you in submitting your insurance claim by providing you with the necessary orthodontic form, filling in our part, and mailing it for you. By signing below, you authorize us to submit claims on the patient's behalf.

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  • Secondary Dental Insurance Information

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  • Subscriber's Signature

  • A dental insurance policy is a contract between the insured and the insurance company. Our professional services are rendered and charged directly to the responsible party. For your convenience, we will gladly assist you in submitting your insurance claim by providing you with the necessary orthodontic form, filling in our part, and mailing it for you. By signing below, you authorize us to submit claims on the patient's behalf.

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