Welcome To The Patient Forms Hub

Important: Please fill out all three forms located on this page if you are a new patient.

If you are a returning patient, then please fill out all forms requested by the front desk personnel.

New Patient And Insurance Info Form (Form 1 of 3)

By clicking the “Submit” button after filling it out, you are agreeing to affix your digital signature to authorize this form. If you have any questions, please call us at: 208 853 4687.

Patient Financial And General Consent Form (Form 2 of 3)

Please fill out the form below. By clicking the “Submit” button after filling it out, you are agreeing to affix your digital signature to authorize this form. If you have any questions, please call us at: 208 853 4687.

Form Agreement

Payment is due at the time of services rendered. For your convenience, we accept cash, credit card, or money order. Financing is available and must be set up prior to the appointment if you wish to participate.

Insurance benefits are determined by your employer and not your dentist. Any deductible or estimated co-pay ment amount is due at the time of treatment. Insurance is not a guarantee of payment; insurance companies will not pay for all your costs. Your insurance policy is a contract between you and your insurer. Your insurance and your payment are still your responsibility.

As a courtesy we will be glad to file your claim for you if you bring 1) your dental insurance card and 2) all required employer information. You will be expected to pay for services rendered if the office is unable to verify your insurance information before treatment. If payment for services already rendered has not been paid in full within 60 days, either by you or your insurance company, the remaining balance for treatment is considered due and collectible.

We reserve the right to charge and collect fees for broken appointments (appointments that are cancelled or broken without 48 hours advance notice). Appointments are reserved exclusively for you; we do not double book our patients. Broken appointment fee is $75.

GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Michael Peterson DDS and/or Eric Ballou DDS to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient's dental condition and needs. I authorize Michael Peterson DDS and/or Eric Ballou DDS to perform any and all forms of treatment, deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Michael Peterson DDS and/or Eric Ballou DDS. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/the patient's health. It is my responsibility to inform the dental office of any change in medical health or status.

I authorize Michael Peterson DDS and/or Eric Ballou DDS and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits, and to handle any necessary claim appeal(s).

Dental And Medical History (Form 3 of 3)

Please fill out the form below. By clicking the “Submit” button after filling it out, you are agreeing to affix your digital signature to authorize this form. If you have any questions, please call us at: 208 853 4687.