Referring Doctor Information

Name of Referring Dentist/Dental Practice

Referring Doctor Phone *

Referring Doctor Email *

Patient X-Ray

Upload Patient X-Ray

Patient's Information

Patient's First Name *

Patient's Last Name *

Patient's Phone Number *

Patient's Date of birth *

Tooth # / Area in Question

Name of Insurance

Dental Insurance Coverage of Patient

Dental Insurance Coverage of Patient *

None

HMO

PPO

Name of Insurance Carrier

Member ID#

What is the Patient's relationship to the Subscriber?

Self

Spouse

Child

Dependent

Name of Subscriber

Subscriber ID#

Choose an Office Near You *

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