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Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Menu
Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Book Now
Insurance Package Forms
Step
1
of
5
20%
Primary Insurance Information
Policy Holder Name
(Required)
First
Last
Policy Holder Date of Birth
(Required)
MM slash DD slash YYYY
Insurance Provider
(Required)
Group Number
(Required)
ID Number
(Required)
We will work with you and your insurance provider regarding your treatment; however, every insurance plan has its own unique set of frequencies and limits.
Due to current privacy laws, many insurance companies will not provide the dental office with any information regarding your plan. Please take the time to fill in this form so we may help you understand your plan properly. You can either call your insurance directly or access your information online.
Knowing your coverage helps
prevent unexpected payment concerns
from your insurance.
Breakdown of Coverage of Primary Insurance
Plan Renewal Month?
January
February
March
April
May
June
July
August
September
October
November
December
What is the annual dollar maximum of benefits allowed?
Does your dental policy include orthodontic coverage?
Yes
No
Don't know
How many units of scaling/root planing are covered?
I could not find the below information regarding hygien units covered.
Per benefit year?
12-month period?
Do You Have a Secondary Insurance
(Required)
Yes
No
Secondary Insurance Information
Secondary Insurance Provider
(Required)
Secondary Group Number
(Required)
Secondary ID Number
(Required)
Breakdown of Coverage of Secondary Insurance
Plan Renewal Month?
January
February
March
April
May
June
July
August
September
October
November
December
What is the annual dollar maximum of benefits allowed?
Does your dental policy include orthodontic coverage?
Yes
No
Don't know
How many units of scaling/root planning are covered?
I could not find the below information regarding hygiene units covered..
Per benefit year?
12-month period?
Your insurance policy is an agreement between you, your employer, and the insurance company that provides your benefits. Not all services may be covered by your insurance and any fees not covered are your responsibility. It is your responsibility to update your insurance information with us whenever your insurance plan coverage may change or if you switch to another insurance provider.
Date
DD slash MM slash YYYY
Policy Holder Signature
Dentistry Made Simple.
Thanks For Filling Out Our Form.