WMT Code : Analytics Code:

Patient Form

PERSONAL INFORMATION

Last Name
First Name
Middle Intial

DENTAL INSURANCE INFORMATION

Primary

Secondary

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPPA)

CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

INSURANCE INFORMATION

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

REQUEST FOR PAYMENT OF BENEEFITS TO PROVIDER OF CARE

CONSENT FOR TREATMENT OF MINOR