Skip to main content
Patient Form

These forms will expedite your visit while in our clinic and will help us to get to know a bit more about you and how to best serve you when visiting us in person, and will only take a few minutes.

OFFICE POLICIES​

AGREEMENT​
I agree to be responsible for all charges for dental services and or materials not paid by my dental plan, unless prohibited by law, or unless Purple Tooth Dental, has a contractual agreement with my plan prohibiting all or a portion of such charges to the extent permitted by law, I consent to the use and disclosure of my protected health information (PHI) to carry out payment activities in connection with any and all claims.​

ASSIGNMENT OF BENEFITS​
I hereby authorize and direct payment of dental benefits (if in network) otherwise payable to me, directly to: Purple Tooth Dental, 112 Woodlawn Ave. Mt. Holly, NC 28120. If my insurance is not in-network with Purple Tooth Dental, I hereby agree to be responsible for all the charges of treatment rendered no later then the day of its completion.​

Please select at least one option.
Please select at least one option.
Please select at least one option.
Please select at least one option.
Thanks for submitting!
Sorry, we were not able to submit the form. Please review the errors and try again.