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Please read the Financial Policies and General Consent Form before continuing. Thank you!

General Consent Form and Financial Policy

Welcome to Beacon Dental Group

Thank you for selecting our dental health care team! We will strive to provide you with the best possible dental care. To help meet all your dental health care needs, please fill out this form completely. If you have any questions or need assistance, Please ask us- we will be happy to help.

"*" indicates required fields

Today's Date*

Name*

Birthday*

Home Phone*

Work Phone

Phone*

Email*

Other Contact

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Status*

Married

Single

Minor

Divorced

Widowed

Please Check*

Male

Female

If Minor, Parent/Guardian Name*

Home Phone*

If Patient is a Student, Name of School/College

Name of Emergency Contact*

Emergency Contact Phone*

Medical Doctor

First Last

Medical Doctor Phone*

Who can we thank for referring you?

First Last

Message

Date*

Name*

First Last

Please Print Name in agreement to the policies stated above.

Date*

Name*

First Last

Please Print Name in agreement to the policies stated above.

Comments

This field is for validation purposes and should be left unchanged.