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Benoit Family and Cosmetic Dentistry and Treatment of TMJ Disorders

We are committed to excellence in dentistry and patient service. Thank you for taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need any assistance, please ask - We will be happy to help.

PERSON RESPONSIBLE FOR ACCOUNT (if other than yourself)

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SPOUSE INFORMATION (EMERGENCY CONTACT INFORMATION IF NOT MARRIED)

Primary Dental Insurance

Click or drag files to this area to upload. You can upload up to 2 files.
Please upload the front and back of your insurance card
SECONDARY DENTAL INSURANCE: PLEASE PRESENT CARD TO FINANCIAL COORDINATOR UPON YOUR VISIT TO OUR OFFICE.