Preliminary Eligibility Form

Verification

Confirmation

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Start Your Journey To A New Smile: Verify Your Insurance Benefits

This is a critical first step. Once submitted, our team verify that your plan is compatible with our medical coverage program. Once we review your coverage, we will reach out to you with your next steps.

Enter the patient's exact details below. Ensure all photos are clear, glare-free, and not cut off to avoid form rejection.

First Name *

Middle Name

Last Name *

Date of Birth *

Phone Number *

Email Address *

Street Address *

City *

State *

ZIP Code *

Front Photo of Valid Drivers License or Passport *

Tap To Upload A Clear Photo

PNG, JPEG or JPG Warning: Expired, blurry, and/or cut-off documents will be rejected and require resubmission.

Front Photo of Patient's Blue Cross Blue Shield Medical Insurance Card *

Tap To Upload A Clear Photo

JPEG, JPG or PNG Warning: Expired, blurry, and/or cut-off documents will be rejected and require resubmission.

Rear Photo of Patient's Blue Cross Blue Shield Medical Insurance Card *

Tap To Upload A Clear Photo

JPEG, JPG or PNG Warning: Expired, blurry, and/or cut-off documents will be rejected and require resubmission.

Note: All fields are required. If you click submit but are not redirected to a confirmation page within a few moments, please review your details and try again.

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