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