Insurance Registration

New Patient & Family Appointment Request

* Indicates required field

Your Name *

First

Last

Cell Phone *

Email *

Who can we thank for referring you? *

How did you find us? *

Select a Service *

Select Day ant Time *

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

Do you have dental coverage? *

Select your dental plan *

Name of the dental plan if not listed above *

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

Subscriber & Employer Information

Who is the dental plan subscriber? *

Subscriber Name *

First

Last

Subscriber's Employer Name *

Subscriber's Date of Birth *

Employers website *

Dental Plan Information:

Member ID # *

Group Number # *

Dental Plan Phone *

Dental Plan Address *

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

2nd Adult Patient Name *

First

Last

Spouse Date of Birth *

Spouse's Relation to Subscriber *

Dependents

1st Dependent Name *

First

Last

1st Dependent Date of Birth *

2nd Dependent Name *

First

Last

2nd Dependent Date of Birth *

3rd Dependent Name *

First

Last

3rd Dependent Date of Birth *

4th Dependent Name *

First

Last

4th Dependent Date of Birth *

Comments *

Submit

mail@papermilldental.com
Text
(404) 465-2379‬

By Appointment Only

Click to set custom HTML

137 Johnson Ferry Road
Suite 2210
Marietta GA 30068

* Fees advertised on website are for new patients, cash only and are Not valid with other offers, coupons or insurance coverage. Certain restrictions apply.
Additional services billed separately. Fees Subject to change. Copyright © 2013 Paper Mill Dental, LLC. All Rights Reserved

New Patient & Family Appointment Request

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

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

Subscriber & Employer Information

Dental Plan Information:

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

Dependents

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

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

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