1 ARD Registration Patient Details

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1 ARD Registration Contact Information

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1 ARD Registration

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1 ARD Registration Emergency Contact Information

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Someone to notify in case of emergency (not living with you)

1 ARD Registration DENTAL INSURANCE 1 ST COVERAGE

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1 ARD Registration DENTAL INSURANCE 2 ND COVERAGE

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1 ARD Registration TERMS OF AGREEMENT

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I attest to the accuracy of the information on this page.

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize release of any information concerning my (or my child’s) health care, advice and treatment to another dentist.

I understand that my dental insurance is a contract between the insurance company, the employer, and me. I understand that Aspen Ridge Dental is NOT responsible, nor can they guarantee how my insurance carrier will pay on a claim. I understand it is my sole responsibility to know my dental carrier’s benefits. I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments-in-full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor.

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