Annual Consents

1045 Garden of the Gods Road, Suite N, Colorado Springs, CO 80907

719-598-3502

Colorado Springs, CO

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General Dentistry
Cosmetic Dentistry
More Services
For Patients
Our Team
Contact
- Book An Appointment

General Dentistry
Cosmetic Dentistry
More Services
For Patients
Our Team
Contact
- Book An Appointment

Annual Consents

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Annual Consents

Annual Consents

Patient Name (First and Last)

I certify that my personal information on file at Mountain Shadows Family Dentistry is true and accurate *

Yes Needs Update

What information do we need to update for you?

I have read and agree to the financial and insurance policies of Mountain Shadows Family Dentistry *

Yes No

I authorize Dr. Holsteen to administer or supervise the administration of such medications or diagnostic and therapeutic procedures as may be necessary for my dental care *

Yes No

I give permission for Mountain Shadows Family Dentistry to use and disclose my protected health information in order to carry out treatment, payment activities and healthcare operations *

Yes No

Do you have insurance that you would like for us to file for you? *

Yes No

I authorize the release of information regarding my dental treatment to my insurance carrier *

Yes No

I authorize my insurance carrier to make payment of my insurance benefits directly to Mountain Shadows Family Dentistry *

Yes No

Please type your date of birth below for verification purposes *

Or, if you are completing this form for someone else, please provide the patient's birth date.

Serving families for over 30 years...

Dan

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Our family have been going here for over twenty years and have never been disappointed. Fantastic people and service. Very easy to recommend...

Lindsey

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Excellent visit. Friendly staff and Dr Holsteen was a pleasure to visit with.

Meganne

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I've been seeing Dr. Holsteen since 1992! The staff is wonderful! They are friendly and they talk to you! They are not robots! (Not to mention they play my favorite oldies station on Pandora when I go in!) I love these professionals because they make you feel at home!



Great people, great practice!

Book an Appointment

Thank you for choosing our office for your family’s oral healthcare needs! We’ve been serving the community in northwest Colorado Springs at our dental office on Garden of the Gods Road for nearly 35 years.

Call or text our office at (719) 598-3502 and let us know what we can do to help you!

Name

Phone Number

Preferred Day

Preferred Time

Additional Notes

Important: Please note that the date and time you requested may not be available. We will contact you to confirm your actual appointment details.

ABOUT OUR PRACTICE

Dr. Daniel Holsteen has been caring for the dental needs of our community for over 32 years.

Our Mission is to become lifetime partners in the healthcare of our patients, to help them to achieve the highest standard of dental care, & to respect their unique and individual needs and desires.