Please complete the form below prior to your first visit. If you have any issues or complications, do not hesitate to contact our office.
A dental insurance policy is a contract between the insured and the insurance company. Therefore, the patient or person responsible
for the account is responsible for paying all fees to our office. We will gladly assist you in submitting insurance claims pertaining to
any charge for care in our office.
To the best of my knowledge, the answers I have given are accurate. I also understand that it is very important to report any changes in my medical
or dental status to Dr. Cordes at the earliest possible time, and I agree to do so. I give permission to Dr. Cordes to obtain from my physician any
additional information regarding my medical history that might be needed to provide me with the best treatment possible.