Grand Rapids Dentist

General Information

Preferred

Y N

Preferred Pronouns

He She They/Them Other

Patient is

Policy Holder Responsible Party

Whom may we thank for referring you to our office?

Responsible Party (if someone different than the patient)

Address/Phone

Birth date

Social Sec #

Drivers Lic #

Responsible party is also the policy holder for

Patient Primary Insurance Secondary Insurance

Primary Insurance Information

Name of Insured

Self Spouse Child Other

Insured Social Sec #

Birth date

Employer

Insurance Company

Group Number

Policy ID #

Secondary Insurance Information

Name of Insured

Self Spouse Child Other

Insured Social Sec #

Birth date

Employer

Insurance Company

Group Number

Policy ID #

ASSIGNMENT & RELEASE

I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balances due and authorize the dentist to release any information for this claim. I authorized that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office I am obligated to pay aid office in accordance with its credit terms and policy. I consent to the making of videotapes, photographs, and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

Signature of Patient/Legal Guardian:

Click to Sign

Date:-------------

Our dental practice exists to help each patient attain a healthy functional and attractive smile. Our entire staff is dedicated to providing modern, quality dental care in a comfortable environment of high level infection control with a skilled, caring and supportive staff. Learn more about our experienced Grand Rapids dentist →

Mon, Wed, Thurs:	8am > 5pm
Tuesday:	10:30am > 7pm
Friday:	By Appointment Only

Dental Digital Marketing by PMAX Dental

Alexandra Dodds DDS

General Information

Patient Information

Responsible Party (if someone different than the patient)

Primary Insurance Information

Secondary Insurance Information

ASSIGNMENT & RELEASE

Click to Sign

New Patients

General Information

Patient Information

Responsible Party (if someone different than the patient)

Primary Insurance Information

Secondary Insurance Information

ASSIGNMENT & RELEASE

Click to Sign