Please fill out this form and attach the requested files, sign, and submit. You can also DOWNLOAD the form here and email it back in at your convenience.
Please bring new dental insurance card with you to your appointment so we can scan it into your file.
To the best of my knowledge, the above information is complete and accurate. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I certify that I, and/or my dependent(s), have insurance coverage with the company as listed and assign directly to Dr. Katherine Hicks all insurance 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 authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance may need during diagnosis and treatment.
*The office schedules individual time with each patient to allow us to deliver the quality, personal care that every patient deserves. I understand that a missed appointment prevents another patient from receiving necessary treatment, and therefore I will be charged $50 should I miss an appointment and fail to cancel 24 hours prior to my appointment.