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Update Your Insurance Information

This form is for DENTAL INSURANCE ONLY. The information you provide will be used to verify your dental and/or orthodontic benefits, so please fill out this form completely and upload a front & back copy of your primary insurance card and a valid ID. As a courtesy, we will verify your new benefits and file insurance claims on your behalf.

For orthodontics, we will bill any outstanding insurance balance to your new insurance carrier as a courtesy. As disclosed at the beginning of treatment, insurance installments vary, and are generally paid over the course of treatment. If for any reason your insurance carrier does not pay the full estimated benefit, the remaining portion will become the guarantor’s responsibility.

    Patient Information

    Patient is an active patient of the following practice(s): (Check all that apply)*

    Billing Party Information

    DENTAL Insurance Information

    Additional family members covered in this policy:

    Family Member 1

    Family Member 2

    Family Member 3

    Family Member 4

    Family Member 5

    Upload DENTAL Insurance (Front)*

    Upload DENTAL Insurance (Back)*

    Upload Drivers License or State ID (Front only)*


    Secondary Dental Insurance Information

    Upload SECONDARY Dental Insurance (Front)*

    Upload SECONDARY Dental Insurance (Back)*

    Contact Info

    Additional Notes/Comments

    *required fields