NEW PATIENT INTAKE FORM

Please fill out this form prior to your appointment with Curtis or Lisa.

MM slash DD slash YYYY
Name(Required)
GENDER(Required)
Address(Required)
MM slash DD slash YYYY

EMERGENCY CONTACT

Name of Emergency Contact(Required)
How did you hear about Signature 28 Denture Clinic?(Required)

INSURANCE COVERAGE

Are you the primary subscriber?
If you answered NO, please provide the name of the primary subscriber:
MM slash DD slash YYYY

FINANCIAL

Please note that a 50% Deposit is collected on the day treatment is started. The balance is due upon delivery. Delinquent accounts are subject to interest charges of 2% per month (26.8% per annum) and third party collection fees.

INFORMATION ABOUT YOUR DENTURES

Do you currently have dental implants?