Please present insurance card to receptionist.

On a scale of 1 (low/not important) to 5 (high/very important) please rate the following:

The information entered above is true to the best of my knowledge. I understand that incorrect information or omission of information can be dangerous in case of an in-office emergency or otherwise. If the patient is a minor, permission is hereby given for dental treatment as deemed necessary to be performed in our office or until written notice is given discontinuing this permission. I agree to be financially responsible for all expenses incurred for myself or my dependents.