Paper Mill Dental

    New Patient & Family Appointment Request 

    Please enter the name of the person filling out this form.

    Dental Insurance/Benefit Plan Information 
    No Coverage? No Problem. We offer patients without coverage the same discounted fees covered patients receive!

    Please choose from the list below.
    Please enter the name of your plan that does not appear in the list above.

    If you do not have a dental benefit plan please type N/A on the required fields below.


    Subscriber & Employer Information

    If you do not have insurance coverage please enter N/A on all required fields.
    The subscriber is the name of the primary person whom the dental plan is registered with. Typically this is the person that work for the company that provides the plan. Example: John Smith works for Coca Cola and is the primary subscriber. His wife and his children are covered under the plan as dependents. If you do not have insurance coverage please enter N/A on all required fields.
    Please provide the name of the employer providing the dental plan. If you do not have insurance coverage please enter N/A on all required fields.
    Please enter the plan subscribers date of birth. If you do not have insurance coverage please enter N/A on all required fields.
    Please enter the employers website. Example www.target.com. If you do not have insurance coverage please enter N/A on all required fields.

    Dental Plan Information:

    The Member ID # is found on your dental plan card. If you do not have insurance coverage please enter N/A on all required fields.
    The dental plan group number isa found on your dental plan card. If you do not have insurance coverage please enter N/A on all required fields.
    This information is found on your dental plan card. If you do not have insurance coverage please enter N/A on all required fields.
    This is the address "For Providers" typically found on the back of your dental plan card. If you do not have insurance coverage please enter N/A on all required fields.

    Family  Members
    Please  add the names of all other family members for whom you wish to make an appointment.



    Dependents





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