Thank you for visiting Gold Coast Family Dental. We want your visit to be pleasant and comfortable. Please fill out this form completely. The better we communicate, the better we can care for you.
PATIENT INFORMATION
First
Last
Middle Initial
Nickname
Street
City
State
Zip
INSURANCE
PRIMARY DENTAL CARRIER
SECONDARY DENTAL CARRIER
Insurance Authorization Statement (Sign & Date)

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature
Date
OTHER INFORMATION
TREATMENT AUTHORIZATION FORMS
I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.
Payment for all treatment and services rendered are my responsibility
Patients Signature
Date
If patient is a child or requires a guardian
Date