Today Date :
Patient's Name :


Employer :

Insurance Company :

Policy # :

Certificate # :



Fee Guide Year :

Deductible ($) :

Benefit year Runs From :

to :


Basic (%) :

Endo (%) :

Diagnostic (%) :

Resto (%) :

Preventive (%) :

Major (%) :

Periodontal (%) :



Maximum for basic services ($) :

Maximum for major services ($) :

Or, Combined yearly maximum ($) :

Frequency :


Complete Exam :

Bitewings :

Recall Exam :

Polish :

FMX :

Fluoride :

Panorex :

Scaling Units :



Orthodontics :


Yes or No :

Maximum Percentage (%) :

Age Limit?



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