Get Edentalsolutions

Filling out the Edentalsolutions form online is a straightforward process designed to gather essential information for your dental visit. This guide will provide you with clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the form

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the patient's name in the appropriate fields. Be sure to fill in the last, first, and middle names as separate entries.
3. Provide the patient's address, including street, apartment number (if applicable), city, state, and zip code. Ensure that each section is filled out completely.
4. Fill in the patient's contact numbers, including home phone, work phone, and cell phone. It is important to provide accurate information so that the office can reach you if needed.
5. Enter the patient’s date of birth and sex. Be mindful that these fields may need specific formatting, such as date features with dropdowns.
6. Indicate the marital status by selecting the appropriate checkbox: married, single, divorced, or widowed.
7. Proceed to enter information regarding the spouse, if applicable, including their name, work address, and occupation.
8. List the patient's/guardian's employer along with their work address, ensuring that you include the correct social security number.
9. Provide emergency contact details, including name, relationship to the patient, and phone numbers.
10. In the insurance and financial information section, indicate whether you have insurance coverage and fill in the relevant details like the insurance company name, subscriber's information, and relationship to the subscriber.
11. Complete any secondary coverage details if applicable, following the same format as for primary insurance coverage.
12. Read through the assignment and release section carefully. Confirm your understanding and consent by signing and dating the form at the bottom.
13. Once you have filled in all required fields, review the information for accuracy. After reviewing, you can save your changes, download the form, print it, or share it.

Get started on your Edentalsolutions document online now.