Serramonte Dental Group
1500 Southgate Ave., Suite 210
Daly City, CA 94015
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Last
First
Nickname
PATIENT(OR PARENT, IF CHILD)
SPOUSE
IF YOU HAVE DENTAL INSURANCE THE FOLLOWING MUST BE COMPLETED IN ORDER TO PROCESS YOUR FORMS:
PRIMARY
SECONDARY
IF OVER 18 AND INSURED UNDER PARENT'S POLICY INDICATE STUDENT STATUS:
FULL TIME STUDENT
PART TIME STUDENT
NOT A STUDENT
NOTE: IF YOU HAVE INSURANCE, WE WILL ASSIST YOU IN COMPLETING THE NECESSARY FORMS. HOWEVER, WE MUST STRESS THAT YOU ARE RESPONSIBLE FOR THE ENTIRE BILL OUR ROLE IS ONLY TO HELP YOU PROCESS YOUR INSURANCE FOR PAYMENT. WE CAN NOT BE RESPONSIBLE FOR ANY FAILURE OF YOUR INSURANCE CARRIER TO PAY FOR THE TREATMENT.
I HEREBY AUTHORIZE ALL DENTAL DIAGNOSTIC PROCEDURES FOR MYSELF OR MY CHILD. IF I DECIDE TO PROCEED WITH TREATMENT, I ALSO CONSENT TO SUCH METHODS, DRUGS AND AGENTS AS MAY BE INDICATED WITH SUCH CARE. THIS CONSENT SHALL REMAIN IN EFFECT UNTIL CANCELLED IN WRITING.