Dental Insurance Worksheet For ________________________

This worksheet will allow you to compare different dental insurance companies and/or discount dental service plans to find the best one for your needs. On the checklist, write in the coinsurance or co-payment rate, if there is one, and any limits on service. 

 

ENTER PLAN NAME -->

 
 
  
Regular Examinations      
Basic Dental Care (Cleanings)      
X-Rays      
Fluoride Treatments      
Root Canals      
Orthodontics (Braces)      
Dentures      
Extractions (Wisdom Teeth)      
Surgery      
False Teeth      
Crowns      
Orthodontics (Braces)      
Fillings      
Other Services (List Below)      
 
      
       
Choice Of Doctors      
Are Referrals Required?      
Ease Of Making Appointments?      
ENROLLMENT FEES:  $  $  $
MONTHLY/ANNUAL FEES:  $  $  $

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