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
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.
Which imaging center is your appointment scheduled at?
San Francisco - Downtown
San Francisco - West Portal
MDI - San Diego
MDI - La Mesa
MDI - Escondido
MDI - Encinitas
Patient Phone #
Date of Next Appointment with Doctor
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.
Name of Primary Subscriber
DOB of Primary Subscriber
Subscriber ID #
Insurance Carrier P.O. Box Address
Is there anything else you would like us to know before your appointment?
Send me a copy of my responses.
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This form was created inside of C-Dental X-Ray.