406.248.3303
1601 Zimmerman Trail, Suite 1
Billings, MT 59102
Monday-Friday 7:30-4:30
Glasgow Office
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The Rimrock Pediatric Dentistry Difference
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Home
About Us
The Rimrock Pediatric Dentistry Difference
Meet Our Doctors
Meet Our Team
Testimonials
Services
Patient Information
First Visit
Policies
Payment & Insurance
FAQ’s
Contact Us
menu
Medical Professional Information
Patient Referral Form
Referring Dentist
Phone #
Child's Name
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Guardian
Guardian Phone #
Primary Dental Insurance
Policy Holder
Employer
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Group ID
Subscriber DOB
Date Format: DD slash MM slash YYYY
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Medicaid #
Chip #
Dollar amount used in our office
Primary Medical Insurance
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Employer
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Group ID
Subscriber DOB
Date Format: MM slash DD slash YYYY
Insurance Mailing Address
Insurance Mailing Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Please mark completed treatment:
Prophy
Fluoride
BW
Occl
Pano
Other
Date of Completed Treatment
Date Format: MM slash DD slash YYYY
Please Mark Recommended Treatment
Please Mark Recommended Treatment: IF IV/GA PLEASE FILL OUT MEDICAL INSURANCE INFO
Oral Sedation
IV Sedation
General Anesthesia
Other
Notes: