Select a location:

Patients

Welcome to Dentistry of the Carolinas! Please tell us about yourself.
Patient’s Last Name:
First Name:
MI:
Title:
Preferred Name:
Birth Date:
MM slash DD slash YYYY
Gender:
- Male
- Female
Billing Address:
Apt/Unit#:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
SSN:
Email:*
Employer:
Occupation:
Marital Status:
How do you prefer to be contacted for appointment confirmation?
- Email
- Phone
Have you been seen at any of our other locations at any time?
- Yes
- No
- If yes, where?
where
Person Responsible for Account (if other than yourself/patient)
Name:
Relationship to Patient:
Birth Date:
MM slash DD slash YYYY
SSN:
Currently a patient in our office?
Billing Address:
City
State
ZIP
Home/Cell Phone:
Work Phone:
Insurance Information
Subscriber Name:
Relationship to Patient:
Subscriber Birth Date:
MM slash DD slash YYYY
Subscriber SSN/ID Number:
Subscriber Employer:
Insurance Company Name:
Insurance Company Phone:
Insurance Authorization
I authorize my insurance company to pay directly to Dentistry of the Carolinas and their associate dentists my insurance benefits that would otherwise be payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or for my dependents. I have received, read, understand and accept DOC’s Explanation of Dental Insurance Benefits. In addition, by signing below I agree to receive calls from DOC staff at work, home, or by mobile phone to discuss matters related to my dental treatment, insurance and financial arrangements.
Patient/Legal Guardian Signature:
Authorization for Treatment
I consent to the procedure decided upon to be necessary or advisable in the opinion of the dentist.
Patient/Legal Guardian Signature:
Date:
MM slash DD slash YYYY
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Dentistry for the New Resident

Gum Disease and Heart Health

Our Dentists are Invisalign Trained

Select a location:

Patients

Welcome to Dentistry of the Carolinas! Please tell us about yourself.

Person Responsible for Account (if other than yourself/patient)

Insurance Information

Insurance Authorization