Insurance Information Form

Patient Information

Please fill out the personal information below. The name and birthday should be those of the patient. The patient is the person who is actually receiving the dental treatment, not his or her parent, guardian, spouse, caregiver, etc. If you are submitting your insurance information in conjunction with an Appointment Request Form, the patient names on both forms should match.

Primary Insured

The name below should correspond to the person who filled out and requested the insurance coverage. This person is the policyowner and is listed as applicant on the premium due page after a policy is issued.

Secondary Insured

If you have secondary insurance i.e., a policy that supplements your primary policy listed above, please provide the information here.