20925 Professional Plaza
Ashburn, VA 20147
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Patient Information and Health History Form
I certify that I, and/or my dependent(s), have insurance coverage with
and assign directly to Dr.
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 above-named insurance Company(ies) and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services.
Place a mark on "yes" or "no" to indicate if you have had any of the following:
Date of last visit
List any medications you are currently taking and the correlating diagnosis: *
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