We request this to provide better service for your dental procedure, so please read carefully and fill it out. Please return completed forms via fax to:
Attention: Front Desk,
Email: [email protected]
Or return to our office prior to the time of your visit. You can download the patients form on our website under Patient Forms.
Please provide your current insurance card and driver’s license or photo identification(s) at the time of your visit or fax them prior to the visit. For new pediatric patients (under 18 years old), we need a copy of the parent or guardian’s ID, and patient’s parent or guardian need to sign on patient forms.
Please read and feel free to ask any questions that you may have concerning these policies. Please adhere to these policies as they assist us in rendering efficient care.
Please read, sign, and return the original to our office before the time of your visit. A copy will be given to you at that time if requested. Please ask to speak to our billing manager if you have any questions.
Again, thank you for choosing Glacier Dental for your dental care needs.
Dr. Jeon and the Staff of Glacier Dental