Dental Statement Enrollment Forms & Samples

Dental Enrollment Forms Enrollment in QUIC Statements Please: print, complete, sign and return (via fax or email) the attached PO. Once received, a QUIC Representative will contact you to begin service implementation. Enrollment in QUIC Statement Inserts Please: print, complete, sign and return (via fax or email) the attached PO. Once received, a QUIC Representative will contact you to begin service implementation. Samples Standard Balance Forward Format #1 Includes a debit and credit column, patient, no doctor column. Current cycle visit detail displayed, previous months’ detail combined into one line balance. Standard Balance Forward Format #2 Includes a single amount and doctor column. Current cycle visit detail displayed, previous months’ detail combined into one line balance. Standard Backer Includes change of patient insurance and patient information boxes. Custom backers, at no additional cost, are offered at time of implementation printed in b/w (graphics included). Color Options Standard statement options offer a variety of colors to choose from.

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