• Patient Information

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    Pick a Date
  • Phone Number

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  • Contact in case of an emergency?

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  • Responsible Party

    (If different from above)
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  • Primary Dental Insurance Information

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  • Patient Dental and Medical History

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    Pick a Date
  • Please select “Yes” or “No” to indicate if you have had any of the following:

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    Pick a Date
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  • *Women:


  • Please select “Yes” or “No” to indicate if you have had any of the following:

  • Authorization and Release

    I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and records of my treatment or examination rendered to me (or my child) during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist any insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services and agree to be responsible for payment of all services rendered on my behalf or my dependents. In the event that I seek credit from the dental office, I consent to release a copy of my credit report to the dental office.
  • Should be Empty:
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