Dr. Desjardins and Dr. Levasseur

St Apollonia Dental Clinic 122 Academy St., Presque Isle, ME 04769

Text or Call
207-554-5045

Request an Appointment

Donate

Dr. Grace Yang

St Apollonia Dental Clinic 122 Academy St., Presque Isle, ME 04769.

Text or Call
207-554-5045

Request an Appointment

Donate

FORM

Dr. Grace Yang

St Apollonia Dental Clinic

122 Academy St., Presque Isle, ME 04769

Request an Appointment DONATE

Patient Registration Form

Patient and Parent Information

Today’s Date:

Patient Name:

Date of Birth:

Address:

City:

Zip:

Home phone:

Cell Phone:

Other Phone:

Maine Care Insurance :

Yes

ID#

Other Insurance:

Yes

If no insurance would you like to apply for sliding fee discount?

YES

Preferred Pharmacy:

City:

Parent Name:

Email:

Free Text

Insurance Information

If your insurance is Maine Care, you do not have to fill this part out. Go to next section

Name of Policy Holder:

Date of Birth:

SS#

Name of Employer:

Insurance Company:

Member ID#

Group#

WorkPhone:

Free Text

CONSENT TO BRING CHILD

We know there are times you cannot bring your child to the dental appointments and must rely on others. This form allows you to give permission for an adult (18 years of age and older) to accompany your child to future appointments. If you wish to change this, ask front desk for another form to update.

Free Text

New Field:

Free Text

give permission for

Field label

Free Text

To bring

New Field:

Free Text

to his/her dental appointments and to make medical and dental treatment decisions on behalf of my child.

Parent/Legal Guardian Signature:

UPLOAD YOUR SIGN