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Dr. J. Belsito Dental

Associates & Specialists Referral

 

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health.

Gender 

Secondary Insurance Information

Do you fall in to another family members insurance plan?

Health Information

Please Select all that Applies to you.

Do you have any other health Concerns / Investigations?

Dental Information
Please select all that applies to you.

Medication
List of Medication(s) your currently taking:

Authorization

I, the undersigned patient, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. This includes all levels of sedation including nitrous oxide (laughing gas) oral sedation and IV (sleep) sedation. Unless other arrangements are made, payment is due at each office visit. My dental insurance is a contract between myself and the insurance company, not between my insurance company and the dentist. I will assume full responsibility for the fees associated with these procedures. I am aware that 2 business days’ notice is required to change or cancel an appointment without charge I agree that Dr. Joseph A. Belsito & Associates can collect, use and disclose personal information about myself or my dependents as set out in the office's privacy policies, and consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. I further agree to receive electronic messages, including text messages, in regards to communicating appointments, requests, information, products, promotions, company news and updates which can be withdrawn at any time. I further consent to being videotaped in public areas of the dental office.

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Find us

Belsitodental.com
2095 Wyandotte St. West

Tel: (519)258-1240

 

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