C-Dental/MDI Patient Check-In Form
In order to expedite your check-in process at our imaging center, please take the time to complete the following form prior to your appointment. If you have a paper copy of your referral slip, please take a picture/scan and email to info@cdental.com before your appointment and include the imaging center location and appointment time in the subject line. We thank you in advance for helping us minimize physical contact.
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Email *
Which imaging center is your appointment scheduled at? *
Required
Patient Name *
Patient Guardian
Patient DOB *
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/
DD
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Patient Phone # *
Referring Doctor *
Patient Address *
Date of Next Appointment with Doctor
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YYYY
Insurance Information for Claim Form
C-Dental is not in-network with Dental insurance carriers, however, C-Dental may assist patients with the filing of insurance claims as a courtesy. Payment is still due at the time of the appointment regardless of insurance coverage. Insurance information must be provided for C-Dental to generate the claim form. Patients must submit their claim form directly to their insurance carrier and follow-up with them as needed.

If you would like us to generate a claim form to submit to your insurance, please provide your dental insurance information below. If you do not have a "subscriber ID" number from your insurance and you typically use your Social Security #, please provide your SS# to the Office Coordinator at the time of your appointment.

Only provide medical insurance information if you were referred to use by a medical doctor.
Insurance Carrier
Name of Primary Subscriber
DOB of Primary Subscriber
Group Number
Subscriber ID #
Insurance Carrier P.O. Box Address
Is there anything else you would like us to know before your appointment?
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