Online Patient Paperwork

Patient Paperwork

Patient Paperwork

Please fill out the fields below to complete your Active Life Dentistry patient paperwork. Fields marked with an asterisk (*) are required. You must complete each page fully before you can move to the next page. Clicking any “Agree” field constitutes your electronic signature, signifying your intent to sign the applicable section, page or document (as applicable), to be as fully binding as if you had entered your signature by non-electronic means.

Patient Information - Page 1 of 7

Employer Information

Emergency Contact

Primary Dental Insurance Information

Do You Have Dental Insurance?

If Patient is Not the Primary Insured

Are You the Primary Insured? *
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