Patient Registration Patient Details

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Welcome! The benefits of a happy, healthy smile are immeasurable! Our goal is to help your child reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you

Patient Registration Contact Information

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Patient Registration

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Patient Registration Primary Dental Insurance

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Patient Registration Secondary Dental Insurance

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Patient Registration Assignment and Release

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I, the undersigned, have insurance with

and assign directly to Oak Tree Pediatric Dentistry all 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 payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

(Please click below to draw/upload sign)
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Thank you for filling out this form completely. It will enable us to help you more effectively. If you have a question at any time, please ask us. We are happy to help.

Our office is HIPAA compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

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