Patient Forms

Check appropriate box:

How did you hear about us?

This information I have given is true and correct. I authorize release of any information relating to my dental treatment to any and all insurance carrier's that may pay benefits for claims submitted for my dental treatment including those whom I am responsible for.

Signed (Responsible Party/Patient or Parent if Minor)

I hereby authorize payment from my insurance carrier of the dental benehits otherwise payable to me directly to Picasso Smile I understand that I am responsible for all cost or dental treatment whether or not my insurance pays for my or whom I am responsible for.