Patient Forms

Online Forms

At Concierge Smile Boutique, we offer patient forms online so you can complete them in the convenience of your own home or office. Complete the forms and bring them with you on your next office visit. Thank you!

woman filling out online dental forms

Patient Registration Form

Check appropriate box:
If College Student
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Household Information or Responsible Party

Insurance Information

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.

Signed (Insured Person)