Patient Information – Des Moines River Dental Care

Please submit the electronic form below. Or you may print this FORM and bring it into the office.

Date of Birth: Dental visits are confirmed by PHONE, TEXT MESSAGE, or EMAIL. Please let us know if you prefer to not receive appointment messages by text or email. Email Yes Text Yes INSURANCE INFORMATION Policy Holder's Date of Birth Effective Date Policy Holder's Date of Birth Effective Date ASSIGNMENT AND RELEASE OF BENEFITS I certify this information is true and correct to the best of my knowledge. Des Moines River Dental Care has my authorization to adhere to my consents outlined on this form. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment. I understand and agree with what I readYes Date of Acceptance: Des Moines River Dental Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.