Patient Information Form

Use the online form below to submit your information online or click here to download and print the form to bring it in with you. All information submitted electronically is encrypted and secure for your privacy.

  • General Info

  • Employer Information

  • Marital Information

  • Minor Information

    If patient is a minor, who is legally responsible?

  • Closest Relative

  • Dental Insurance

  • Dental History

  • Medical History

    If so, please List.

  • Check the box for all that apply.

  • Payment is due when services are rendered unless prior financial arrangement have been made.

    A FINANCE CHARGE, computed at a periodic rate of 1.5% monthly (18% annually), will be applied to my balance outstanding sixty (60) days or greater. I am responsible for Alamont’s reasonable collection costs, including court costs and attorney fees. My balance is due within twenty-five (25) days from the billing date shown on my monthly statement unless I have made other arrangements.

    I hereby authorize Alamont, any credit bureau, or other investigating agency to investigate or obtain any data pertaining to my credit or financial responsibilities.