Your Name (required)
Your Email (required)
Date of Birth
City: State: Zip:
If patient is a child:
Subscriber's Date of Birth
Name and Phone # of 2 persons whom we may contact in case of emergency
Name of previous dentist where records could be obtained, if necessary
Whom may we thank for this referral?
Verification: Enter These Characters Below
PAYMENT IS DUE AS SERVICES ARE RENDERED. We will gladly file your insurance claim for you. A service charge of .66% per month (7.92% annually) will be automatically added to any balance over 60 days. A $25.00 fee will be charged on all returned checks.
I understand that responsibility for payment for dental services provided in this office for myself, or my dependents, is mine, due and payable at the time services are rendered unless financial arrangements have been made. If insured, I authorize any insurance payment to go directly to Dr. Robert Derr.
Signature: Please Sign Below
(After you click Submit, please make sure you complete both forms)
We can help to schedule you soon with one of our great Doctors
Specific date you would prefer
Specific time you would prefer
General day(s) of the week would you like to come in
General time(s) of the day would you like to come in
Please describe your appointment