• Patient Registration Form 

    By filling this out you are authorizing Beautiful Smiles Denture Clinic to phone & email you. We respect your privacy and do not tolerate spam and will never sell, rent, lease or give away your information (name, address, email, etc.) to any third party.


  • Personal Information 

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  • Insurance Information 

  • Primary Insurance 

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  • Secondary Insurance 

    We are only able to direct bill to your primary insurance. However, we are happy to send pre-authorizations and claims to your secondary insurance on your behalf

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  • Government Funding 

  • Medical History 

  • Check all that apply 

  • Cancellation Policy: 
    Any cancellations within 24 hours or fail to show for an appointment will be charged with a fee of $40. After 3 short notice cancellations/no shows we will not be able to continue our services.

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