• Welcome

    We are pleased to welcome you to Virtue Dental Care. Please take a few minutes to read and fill out this form completely. If you have any questions, we are glad to help you.
  • Patient information

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  • Primary Insurance

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  • Dental History

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  • Medical History

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  • Women Only

  • Authorization

  • I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there are any changes in my medical status, I will inform the dentist.

    I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for the services rendered. I authorize the use of the signature on all insurance submissions

    I authorize the dentist to release all information necessary to secure the payment of benefits. I understand I am financially responsible for all charges that were or not paid by insurance.

  • Clear
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  • Payment Is due in full at the time of treatment, unless prior arrangements have been approved

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