Tell Us About Yourself

Insurance – Primary

Insurance – Secondary

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Today’s Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

Medical History

Nearest relative not living with you:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Dental History

Here at Today’s Dental we offer a wide variety of services to enhance and keep your smile beautiful. Please circle any services below you would like our friendly staff to discuss with you during your visit.