New Patient Form | Jefferson Dental & Orthodontics

Thanks for choosing Jefferson Dental & Orthodontics! To speed up your check-in, please fill out this form.
What area are you in?*
Which office do you plan to visit?*
Which office do you plan to visit?*
Which office do you plan to visit?*
Which office do you plan to visit?*
Which office do you plan to visit?*

Insurance Info
Please upload photos of the front and back of your insurance card.*
Please upload photos of the front and back of your insurance card.
Drop files here or

Accepted file types: jpg, png, pdf, gif, Max. file size: 2 MB.

Agreement
Please review the following information.*
- I acknowledge that this information is correct and will be held in the strictest confidence.
- I authorize Jefferson Dental & Orthodontics to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
- Payment is due in full at the time of treatment unless prior arrangements have been approved. I understand that I am responsible for paying any copayment and deductibles that my insurance does not cover, if applicable.
- I hereby authorize payment directly to Jefferson Dental & Orthodontics of the group insurance benefits otherwise payable to me, if applicable.
- I hereby authorize release of any information including the diagnosis and records of treatment or examination rendered to my insurance company, if applicable.
Optional
- I authorize Jefferson Dental & Orthodontics to contact me regarding promotions and services.
Signature*
Please enter your full first and last name and date below to represent your signature. You may also sign this form once you arrive to the office for your appointment.
Date Submitted*
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Comments
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Thanks for choosing Jefferson Dental & Orthodontics! To speed up your check-in, please fill out this form.