Please complete the form below in advance of your appointment with Toothworks.
This secured webform has been optimized for touch-screen devices and can be signed with a stylus, your finger or with a mouse.
Please Read: If your dental benefits plan allows it, Toothworks will submit your claims electronically on your behalf or provide you the paperwork necessary to make your claim. If you have not done so already, we recommend you register with your insurance carrier's online client dashboard and request direct deposit for speedy reimbursements. In order to assist you by submitting claims electronically on your behalf, we require you fill out the information requested below.
Please enter your spouse's / guardian's details below
I have provided an accurate medical and dental history and have not knowingly omitted any information. I further understand that information provided from or to my medical doctor, previous dentist or insurance company may become necessary and I consent to having this information released.
I further understand that the financial responsibility of the dental services for me and my dependents is mine and I assume all responsibility for fees associated with these services.
If your device is equipped with a stylus or touch screen, please sign where indicated below. You can sign with a mouse if using a desktop computer. If you are not able to sign, you can send your digital form without a signature and sign a paper form in our office.