Forms

Customizable and user friendly patient intake forms, consent forms built to get done quick and easy.

Dashboard

Automated Request

Axle will automatically request forms based on the patient’s appointment type.

Form Grouping

Collect, combine and insert specific forms into your PMS.

Website Integration

Axle gives you the tools you need to grow without having to overpay for services.

Forms Simulator

Take Axle forms for a spin just as if you were a patient

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Step 1: Patient Information

Patient Information

  • Alabama (AL)
  • Alaska (AK)
  • Arizona (AZ)
  • Arkansas (AR)
  • California (CA)
  • Colorado (CO)
  • Connecticut (CT)
  • Delaware (DE)
  • District Of Columbia (DC)
  • Florida (FL)
  • Georgia (GA)
  • Hawaii (HI)
  • Idaho (ID)
  • Illinois (IL)
  • Indiana (IN)
  • Iowa (IA)
  • Kansas (KS)
  • Kentucky (KY)
  • Louisiana (LA)
  • Maine (ME)
  • Maryland (MD)
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  • Michigan (MI)
  • Minnesota (MN)
  • Mississippi (MS)
  • Missouri (MO)
  • Montana (MT)
  • Nebraska (NE)
  • Nevada (NV)
  • New Hampshire (NH)
  • New Jersey (NJ)
  • New Mexico (NM)
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  • Oklahoma (OK)
  • Oregon (OR)
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  • Rhode Island (RI)
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  • South Dakota (SD)
  • Tennessee (TN)
  • Texas (TX)
  • Utah (UT)
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming

Contact Information

Need help completing this form?

Text us: +1 (877) 651-3141

Email us: hello@meetaxle.com

Graf Dental Surgery

8714 Tennyson Ave, Wheelersburg, OH 45694

Key Eligibility Features

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    Auto-categorize

    Axle categorizes fields, forms and values into your PMS so that the patient’s profile always matches Axle.

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    Form finder

    Automatically collect overdue forms before the patient arrives in the office to speed up check-in.

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    Smart link

    Use Axle smart link to integrate your forms or share a link with a patient and Axle will find where to insert the form.

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    Mix and match forms

    Select unique forms you want only certain patients to receive a long with still sending your regular forms.

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    Full white-label

    All patient communication and experience is customizable to your practice branding.

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    Form builder

    Build and integrate fully custom digital forms with the way you want them to look and function.

Features

Explore more Axle features

Features Icon

Eligibility AI insurance verification

  • Unlimited real-time eligibility verifications
  • Auto insert eligibility into practice PMS
  • Auto-pilot AI insurance verification
  • 162+ insurance carriers
Features Icon

Reviews Automated review collection

  • Automated review request
  • Negative review management
  • Multi-location reputation overview
  • Flexible and customizable configuration
Features Icon

Scheduling Self-service scheduling

  • Real-time online self scheduling
  • Integratabtle online scheduling link
  • Customizable appointment settings
  • Full white-label landing page

Ready to see how AXLE can transform your dental practice?

Insurance Carrier List

Unlock Payer list

  • AARP

    Payer ID: AARP1
  • Advantica Benefits

    Payer ID: 43168
  • Aetna US Healthcare

    Payer ID: 60054
  • AFLAC NY

    Payer ID: 52080
  • Alabama Medicaid

    Payer ID: CKAL1
  • Altus

    Payer ID: 50503
  • American Family Life Assurance Co. (AFLAC)

    Payer ID: 58066
  • Ameritas Life Insurance Company

    Payer ID: 47009
  • Ameritas Life Insurance Corp.

    Payer ID: 47009
  • Ameritas Life insurance Corp. of New York

    Payer ID: 72630
  • Anthem Blue Cross

    Payer ID: 47198
  • Arizona Medicaid

    Payer ID: CKAZ1
  • Blue Cross Blue Shield Delaware Fully – Insured Dental Group Business

    Payer ID: 53287
  • Blue Cross Blue Shield of Kansas City MO

    Payer ID: 47171
  • Blue Cross Blue Shield of Massachusetts

    Payer ID: CBMA1
  • Blue Cross Blue Shield of Michigan

    Payer ID: CBMI1
  • Blue Cross Blue Shield of New York (Empire)

    Payer ID: CBNY1
  • Blue Cross Blue Shield of South Carolina

    Payer ID: 38520
  • Blue Cross Dental

    Payer ID: CBMNU
  • Blue Cross of Alabama

    Payer ID: CBAL1
  • Blue Cross of Alaska and Washington

    Payer ID: 47570
  • Blue Cross of Arkansas

    Payer ID: CBAR1
  • Blue Cross of Colorado

    Payer ID: 84099
  • Blue Cross of Kansas

    Payer ID: CBKS1
  • Blue Cross of Massachusetts

    Payer ID: CBMA1
  • Blue Cross of Rhode Island

    Payer ID: CB870
  • BlueCross BlueShield of Michigan

    Payer ID: 580
  • BlueCross BlueShield of National Capital Area (CareFirst)

    Payer ID: 580
  • California Medicaid – Medi-Cal

    Payer ID: 94146
  • CareFirst, Inc. Maryland BCBS

    Payer ID: 00580
  • CareSource

    Payer ID: CKOH2
  • CIGNA

    Payer ID: 62308
  • CompBenefits

    Payer ID: CX021
  • Consumers Life Insurance Company

    Payer ID: CB833
  • Cooperative Benefit Administrators

    Payer ID: 52132
  • CoOportunity Health

    Payer ID: CX009
  • Coresource Little Rock

    Payer ID: 75136
  • Coventry Dental

    Payer ID: CX049
  • DBP – Americhoice (NJ/PA) / UHC (MS)

    Payer ID: 52133
  • DBP – Americhoice (NJ/PA) / UHC (MS)

    Payer ID: GP133
  • DBP – Americhoice (NJ/PA) / UHC (MS)

    Payer ID: 196
  • DeCare Dental Health Insurance

    Payer ID: 7035
  • Delta Dental (Northeast) (ME, NH, VT)

    Payer ID: 2027
  • Delta Dental CA FedVIP

    Payer ID: CDCA1
  • Delta Dental District of Columbia

    Payer ID: 52147
  • Delta Dental Ins. Co. – Mississippi

    Payer ID: DDLA1
  • Delta Dental Insurance Co. (DDIC)

    Payer ID: 94276
  • Delta Dental Insurance Co. (DDIC) – All Payers

    Payer ID: 94276
  • Delta Dental of Alabama (DDIC)

    Payer ID: 94276
  • Delta Dental of Alaska (DDIC)

    Payer ID: 94276
  • Delta Dental of Arizona

    Payer ID: 86027
  • Delta Dental of Arkansas

    Payer ID: CDAR1
  • Delta Dental of California – CA00 Claims Office

    Payer ID: 77777
  • Delta Dental of Delaware

    Payer ID: 51022
  • Delta Dental of Florida (DDIC)

    Payer ID: 94276
  • Delta Dental of Georgia (DDIC)

    Payer ID: 94276
  • Delta Dental of Idaho

    Payer ID: 82029
  • Delta Dental of Illinois Group Plans

    Payer ID: 5030
  • Delta Dental of Indiana

    Payer ID: CDIN1
  • Delta Dental of Iowa

    Payer ID: CDIA1
  • Delta Dental of Iowa – Dental Wellness Plan

    Payer ID: CDIAM
  • Delta Dental of Iowa Medicaid Program

    Payer ID: CDIAM
  • Delta Dental of Kansas

    Payer ID: CDKS1
  • Delta Dental of Kentucky

    Payer ID: CDKY1
  • Delta Dental of Louisiana (DDIC)

    Payer ID: 94276
  • Delta Dental of Louisiana (DDIC)

    Payer ID: DDLA1
  • Delta Dental of Maryland and Pennsylvania

    Payer ID: 23166
  • Delta Dental of Massachusetts

    Payer ID: 4614
  • Delta Dental of Michigan

    Payer ID: CDMI0
  • Delta Dental of Minnesota

    Payer ID: CDMN1
  • Delta Dental of Mississippi (DDIC)

    Payer ID: 94276
  • Delta Dental of Missouri

    Payer ID: 43090
  • Delta Dental of Montana (DDIC)

    Payer ID: 94276
  • Delta Dental of Nebraska

    Payer ID: CDNE1
  • Delta Dental of Nevada (DDIC)

    Payer ID: 94276
  • Delta Dental of New Jersey

    Payer ID: 22189
  • Delta Dental of New Mexico

    Payer ID: 85022
  • Delta Dental of New York

    Payer ID: 11198
  • Delta Dental of North Carolina

    Payer ID: 56101
  • Delta Dental of North Dakota

    Payer ID: CDND1
  • Delta Dental of Ohio

    Payer ID: CDOH1
  • Delta Dental of Oklahoma

    Payer ID: CDOK1
  • Delta Dental of Puerto Rico

    Payer ID: DDDPR
  • Delta Dental of Rhode Island

    Payer ID: 5029
  • Delta Dental of South Carolina

    Payer ID: 43091
  • Delta Dental of Tennessee

    Payer ID: CDTN1
  • Delta Dental of Texas (DDIC)

    Payer ID: 94276
  • Delta Dental of Utah (DDIC)

    Payer ID: 94276
  • Delta Dental of Washington

    Payer ID: 91062
  • Delta Dental of Washington DC

    Payer ID: 52147
  • Delta Dental of West Virginia

    Payer ID: 31096
  • Delta Dental of Wisconsin

    Payer ID: 39069
  • Delta Dental Puerto Rico

    Payer ID: 66043
  • DeltaCare USA

    Payer ID: CDCAP
  • DeltaCare USA Claims

    Payer ID: DDCA2
  • DeltaCare USA Encounters

    Payer ID: DDCA3
  • Denex Dental

    Payer ID: CX049
  • Dental Benefit Providers

    Payer ID: 196
  • DentaQuest – Goverment Plans

    Payer ID: CKMD1
  • DentaQuest – Government Plans

    Payer ID: CX014
  • DentaQuest – Government Plans

    Payer ID: CX052
  • DentaQuest – Government Plans

    Payer ID: CKID1
  • DentaQuest – Government Plans

    Payer ID: CKIL1
  • DentaQuest – Government Plans

    Payer ID: CKKY3
  • DentaQuest – Government Plans

    Payer ID: CKMD1
  • DentaQuest – Government Plans

    Payer ID: CKSC1
  • DentaQuest – Government Plans

    Payer ID: 62154
  • DentaQuest – Government Plans

    Payer ID: CKVA1
  • DentaQuest – Government Plans Florida

    Payer ID: CKSC1
  • DentaQuest – Government Plans Florida

    Payer ID: CX052
  • DentaQuest – Government Plans WI

    Payer ID: CX014
  • DentaQuest Gov Services

    Payer ID: 62154
  • Dentist Direct

    Payer ID: UTUDD
  • Dentist Direct LLC

    Payer ID: UTUDD
  • District of Columbia Medicaid

    Payer ID: CKDC1
  • EHI

    Payer ID: 73288
  • Emblem Health

    Payer ID: 13551
  • Emblem Health (GHI – New York Group Health Inc.)

    Payer ID: 13551
  • Emblem Health (GHI HMO)

    Payer ID: 13551
  • Emblem Health (HIP ? Health Insurance Plan of Greater NY)

    Payer ID: 13551
  • EMPHESYS

    Payer ID: 73288
  • Empire Blue Cross and Blue Shield

    Payer ID: CBNY1
  • Empire Blue Cross Blue Shield

    Payer ID: CBNY1
  • Employers Health Insurance

    Payer ID: 73288
  • Everence

    Payer ID: 35605
  • Financial Reliance Ins Co (NY Business)

    Payer ID: AMTAS00428
  • First Ameritas Life Insurance Corporation of New York

    Payer ID: 72630
  • First Ameritas of New York

    Payer ID: 72630
  • First Reliance Standard Life Ins Co.

    Payer ID: 13317
  • First Reliance Standard Life Ins Co. (NY Business)

    Payer ID: AMTAS00428
  • First Reliance Standard Life Ins. Co. (NY Business)

    Payer ID: 13317
  • First Reliance Standard Life Insurance Co

    Payer ID: AMTAS00428
  • GDS

    Payer ID: CX036
  • Government Employees Health Association (GEHA)

    Payer ID: 44054
  • Government Employees Health Association,Inc. (GEHA)

    Payer ID: 57254
  • Government Employees Hospital Association (GEHA)

    Payer ID: 44054
  • Government Employees Hospital Association (GEHA)

    Payer ID: 57254
  • Great-West Healthcare

    Payer ID: 80705
  • Group Health Coop (Individual & Family, and Small Business Groups)

    Payer ID: CX007
  • Guardian Individual Plan

    Payer ID: GI813
  • Guardian Life Insurance Company of America

    Payer ID: 64246
  • Health Choice Arizona

    Payer ID: 6179
  • Health Choice Arizona

    Payer ID: 62179
  • Health Plan of Nevada / Sierra Health

    Payer ID: 76342
  • HealthPartners MN

    Payer ID: CX009
  • Healthplex, Inc.

    Payer ID: 11271
  • HealthSmart Benefit Solutions

    Payer ID: 320
  • Horizon Blue Cross Blue Shield of New Jersey

    Payer ID: 22099
  • Horizon Healthcare Dental Services

    Payer ID: 22099
  • Horizon Healthcare of NY

    Payer ID: 22099
  • Humana

    Payer ID: 73288
  • Humana Dental

    Payer ID: 73288
  • Idaho Medicaid

    Payer ID: CKID1
  • Kaiser

    Payer ID: CX073
  • Kaiser NW Dental

    Payer ID: CX073
  • Kentucky Medicaid

    Payer ID: 63
  • Kentucky Spirit

    Payer ID: 65030
  • LA BCBS AdvantagePlus Network

    Payer ID: 53021
  • Lincoln Financial Group

    Payer ID: CX061
  • Lincoln FINANCIAL INSURANCE COMPANY

    Payer ID: CX061
  • Lincoln National (WI)

    Payer ID: 73288
  • Managed Dental Guard

    Payer ID: GI813
  • MAPFRE

    Payer ID: PRFRE
  • Maryland Medicaid

    Payer ID: CKMD1
  • Massachusetts Health Program

    Payer ID: CKMA1
  • Massachusetts Medicaid

    Payer ID: CKMA1
  • MCNA Dental

    Payer ID: 65030
  • Medicaid of Arkansas

    Payer ID: CKAR1
  • Medicaid of Colorado

    Payer ID: CKCO1
  • Medicaid of Connecticut

    Payer ID: CKCT1
  • Medicaid of Florida

    Payer ID: CKFL1
  • Medicaid of Georgia

    Payer ID: CKGA1
  • Medicaid of Indiana

    Payer ID: CKIN1
  • Medicaid of Iowa

    Payer ID: CKIA1
  • Medicaid of Kansas

    Payer ID: CKKS1
  • Medicaid of Kentucky

    Payer ID: CKKY1
  • Medicaid of Maine

    Payer ID: CKME1
  • Medicaid of Michigan

    Payer ID: CKMI1
  • Medicaid of Minnesota

    Payer ID: CX026
  • Medicaid of Minnesota

    Payer ID: CKMN1
  • Medicaid of Mississippi

    Payer ID: CKMS1
  • Medicaid of Missouri

    Payer ID: CKMO1
  • Medicaid of Montana

    Payer ID: CKMT1
  • Medicaid of Nevada

    Payer ID: CKNV1
  • Medicaid of New Hampshire

    Payer ID: CKNH1
  • Medicaid of New Jersey

    Payer ID: CKNJ1
  • Medicaid of New Mexico

    Payer ID: CKNM1
  • Medicaid of New York

    Payer ID: CKNY1
  • Medicaid of New York (Dental Clinics Only)

    Payer ID: CKNY2
  • Medicaid of North Carolina

    Payer ID: CKNC1
  • Medicaid of Ohio

    Payer ID: CKOH1
  • Medicaid of Oklahoma

    Payer ID: CKOK1
  • Medicaid of Oregon

    Payer ID: CKOR1
  • Medicaid of Pennsylvania

    Payer ID: CKPA1
  • Medicaid of South Dakota

    Payer ID: CKSD1
  • Medicaid of Texas

    Payer ID: CKTX1
  • Medicaid of Vermont

    Payer ID: CKVT1
  • Medicaid of Washington

    Payer ID: CKWA1
  • Medicaid of West Virginia

    Payer ID: CKWV1
  • Medicaid of Wisconsin

    Payer ID: CKWI1
  • Medicaid of Wyoming

    Payer ID: CKWY1
  • Medical Card System (MCS)

    Payer ID: PRMCS
  • Medical Mutual of Ohio

    Payer ID: 29076
  • Medical Mutual of Ohio

    Payer ID: CB833
  • MetLife

    Payer ID: 65978
  • Montana Medicaid

    Payer ID: CKMT1
  • Montana Medicaid – DPHHS/Health Policy Services Division

    Payer ID: CKMT1
  • MVP Health Care

    Payer ID: 14165
  • Nevada Medicaid – First Health Services Corp

    Payer ID: CKNV1
  • Nippon Life Insurance Company of America

    Payer ID: 81264
  • North Dakota Medicaid

    Payer ID: CKND1
  • Northeast Delta Dental (ME, NH, VT)

    Payer ID: 2027
  • NorthStar Administrators

    Payer ID: 47570
  • NorthStar Administrators

    Payer ID: 47570
  • OH Dental / UHC Dental Government Programs

    Payer ID: GP133
  • Optum Specialty Svcs / Americhoice of NJ

    Payer ID: GP133
  • Pacificare Dental and Vision HMO

    Payer ID: CX060
  • Pacificare Dental and Vision PPO

    Payer ID: CX053
  • Pennsylvania Blue Shield

    Payer ID: CB865
  • Pennsylvania Blue Shield (Camp Hill)

    Payer ID: CB865
  • Pennsylvania Blue Shield Dental Plus

    Payer ID: CBPA2
  • Premera Blue Cross

    Payer ID: 47570
  • Premier Health Systems, Inc.

    Payer ID: CB833
  • Principal Financial Group

    Payer ID: 61271
  • Principal Financial Group

    Payer ID: 61271
  • Principal Financial Group

    Payer ID: PFINL
  • Principal Life Insurance Co.

    Payer ID: 61271
  • Principal Life Insurance Company

    Payer ID: 61271
  • Prominence Preferred Health Insurance Company

    Payer ID: PPHIC
  • Reliance Standard Life

    Payer ID: 36088
  • Reliance Standard Life Insurance Company

    Payer ID: 36088
  • Securian

    Payer ID: 93742
  • Sierra Health and Life

    Payer ID: 76342
  • Sierra Health Services

    Payer ID: 76342
  • Standard Ins. Co. (OR Business)

    Payer ID: 93024
  • Standard Insurance Company

    Payer ID: 93024
  • Standard Insurance Company (NY)

    Payer ID: 13411
  • Standard Life Insurance Company of New York

    Payer ID: 13411
  • State of Texas Dental Plan

    Payer ID: 73288
  • TDC

    Payer ID: 73288
  • Tennessee Medicaid

    Payer ID: CKTN1
  • Tennessee Medicaid – Tenncare

    Payer ID: CKTN1
  • The Dental Companies

    Payer ID: 73288
  • The Dental Concern

    Payer ID: 73288
  • Travelers (now MetLife)

    Payer ID: 65978
  • TRICARE Dental Program

    Payer ID: CX007
  • Triple-S Medicaid Advantage

    Payer ID: PRADV
  • Triple-S Medicare Advantage

    Payer ID: PRADV
  • Triple-S Salud

    Payer ID: CBPR1
  • Triple-S Salud (BCBS PR)

    Payer ID: CBPR1
  • Trustmark

    Payer ID: 61425
  • Trustmark Insurance Company

    Payer ID: 61425
  • UMR – Cincinnati

    Payer ID: 33108
  • UMR – Cincinnati

    Payer ID: 39026
  • UMR – Harrington

    Payer ID: 95266
  • UMR – Harrington

    Payer ID: 75196
  • UMR – Harrington/Columbus

    Payer ID: 39026
  • UMR – Lexington

    Payer ID: 39026
  • UMR – Onalaska

    Payer ID: 39026
  • UMR – Onalaska

    Payer ID: 79480
  • UMR – Sant Antonio

    Payer ID: 39026
  • UMR – Wausau/UHIS

    Payer ID: 39026
  • UMR – Wausau/UHIS

    Payer ID: 39026
  • UMR Wausau

    Payer ID: 39026
  • United Concordia – Dental Plus

    Payer ID: CX013
  • United Concordia – Fee for Service

    Payer ID: CX007
  • United HealthCare Insurance Company – Student Insurance

    Payer ID: 74227
  • UnitedHealthcare Community Plan TN

    Payer ID: 95378
  • UnitedHealthcare Dental

    Payer ID: 52133
  • UnitedHealthcare StudentResources

    Payer ID: 74227
  • Valley Baptist Health Plan

    Payer ID: CX007
  • Wellchoice of NJ

    Payer ID: CBNY1