Paper Mill Dental - General Cosmetic Implant Dentistry Serving Marietta, Atlanta, Roswell, Sandy Springs
New Patient & Family Appointment Request
*
Indicates required field
Your Name
*
First
Last
Please enter the name of the person filling out this form.
Cell Phone
*
Email
*
Who can we thank for referring you?
*
How did you find us?
*
My Insurance
Mt Bethel Elementary
Sope Creek Elementary
Taste of East Cobb
Social Media Facebook, Google + etc
Referred by Friend, Family or Healthcare Provider
Select a Service
*
Consult
New Patient Exam, Cleaning & X-rays
Emergency Exam & X-rays
Teeth Whitening
Dental Implant(s)
Implant Restorations Crown(s) or Bridge
Crown & Bridge
Dentures & Partials
Select Day ant Time
*
Monday - AM
Monday - PM
Tuesday - AM
Tuesday - PM
Wednesday - AM
Wednesday - PM
Thursday - AM
Thursday - PM
Friday - AM
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?
*
Yes
No - No worries....you will receive discounted fees
Select your dental plan
*
Select from list
Aetna PPO
Ameritas
Assurant
Blue Cross Blue Shield
Cigna PPO
Delta Dental PPO
Guardian PPO
Met Life PPO
United Concordia
United Healthcare
Principal
My plan is not listed
I do not have a dental plan
Please choose from the list below.
Name of the dental plan if not listed above
*
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
Who is the dental plan subscriber?
*
I am the primary plan subscriber
My husband is the primary plan subscriber
My wife is the primary plan subscriber
My father is the primary plan subscriber
My mother is the primary plan subscriber
I do not have a dental plan
If you do not have insurance coverage please enter N/A on all required fields.
Subscriber Name
*
First
Last
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.
Subscriber's Employer Name
*
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.
Subscriber's Date of Birth
*
Please enter the plan subscribers date of birth. If you do not have insurance coverage please enter N/A on all required fields.
Employers website
*
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:
Member ID #
*
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.
Group Number #
*
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.
Dental Plan Phone
*
This information is found on your dental plan card. If you do not have insurance coverage please enter N/A on all required fields.
Dental Plan Address
*
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.
2nd Adult Patient Name
*
First
Last
Spouse Date of Birth
*
Spouse's Relation to Subscriber
*
Husband
Wife
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