This form contains all of your basic personal and insurance plan information, which will help us streamline your benefits and customize your care.
Have a secondary insurance? Please fill out the form below.
Your dental history tells us everything we need to know about your past experience, sensitivity, and current concerns.
Your medical history is unique to you. Understanding your needs will help us provide a personalized, comfortable visit – every time.
We are happy to help you maximize your dental benefits, if you have them. Please read, sign and return this form.
Don’t have any insurance? Join our KeySmile Membership Program
Caries Risk Assessment
Our team is passionate about ending cavities. This form helps us start the process.