Insurance Form

Simply Wisdom Teeth Insurance Information Sheet

Please complete this form to give us your most up to date Dental Insurance information. Once we have this information we will be able to give you an exact cost for having your wisdom teeth removed.

*PLEASE NOTE: This must be Dental Insurance, Wisdom Teeth will not be covered by Medical Insurance*

Today's Date

Caller's Name

Contact Phone #

Secondary Phone #

Patient's Name

Patient's DOB

Patient's Address

*The subscriber is the person who pays for coverage or who's employer offers the coverage*

Subscriber's Name

Subscriber's DOB

Subscriber's Address

*The following information can be found on the insurance card issued by your employer*

Insurance Company Name

Insurance Company Phone#

Insurance Company Address

Subscriber or Member ID#

Group #

Group Name

Payor ID#

Employer

If you are human, leave this field blank.

Simply Wisdom Teeth Insurance Information Sheet

Send us a message

Phone:

Email

Address:

Great News!
You're eligible, but with different insurance plans the cost will vary between providers

We estimate pricing to be around $50-$600

Simply Wisdom Teeth Insurance Information Sheet

Send us a message

Phone:

Email

Address:

Great News!You're eligible, but with different insurance plans the cost will vary between providers We estimate pricing to be around $50-$600

Great News!
You're eligible, but with different insurance plans the cost will vary between providers

We estimate pricing to be around $50-$600