New Patient Form About You Today's Date Gender: FemaleMale Birthdate: Status: MinorSingleMarriedDivorcedSeparatedWidowed Do you have children? YesNo Primary Dental Insurance Secondary Dental Insurance [cf7mls_step AccountInfo placeholder"Account Info" "]"] Account Info Payment Method: CashCheckCredit Card I hereby Authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office) In Event of Emergency
