Annual Consents - Mountain Shadows Family Dentistry

Patient Name *

First

Last

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

Yes
Needs Update

Have you moved or changed your phone numbers or email address? Please let us know so that we can update your patient record.

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

Our policies regarding payments on accounts and insurance are available for your review on our Patient Resources page.

I authorize Dr. Rivard 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

Form Validation

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.