Interested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you!

You must be the Legal Guardian of the patient, or the patient (If 18+ years old). Others may not fill out this form.

You will need the following ready to complete this form:

Physical copies or images of Insurance card(s)
Physical copy of state identification (driver's license)
Primary dental office information (Name of office and practice telephone number)
Personal information (Patient and or parent's Date of Birth, Social Security Number, address, etc)

Let’s work together

Secure online patient intake form for oral surgery at Lafayette practice

Email

Phone

(###)

###

####

Is the Patient 18 years or older?

Yes (Patient is an adult, 18+)

No (Patient is a minor under the age of 18)

Which office location do you prefer to be seen at?

Patient Name

First Name

Last Name

Patient Email

Patient Phone

(###)

###

####

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Birth Date

MM

DD

YYYY

Patient Gender

Male

Female

What type of dental insurance does the patient have?

Louisiana Medicaid EPSDT MCO Plan (DentaQuest/MCNA)

Single Primary PPO Plan

Primary Insurance + Louisiana Medicaid

Primary and Secondary PPO Plan

None/Cash

You must be the Legal Guardian of the Patient or the Patient (if 18 years of age or older) to complete this form. Others may not fill out this form. In addition to completing and submitting the Patient Intake Form, the Authorization Form below must be completed and signed.

Let’s work together

Contact Information

Patient Information

Services