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  • New Patient Health History

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  • Financial Party Information

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  • Dental History

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  • Medical History

  • Patients Under 18

  • Liability

    I understand that the information that I have given today is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. If this office accepts my insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible(s) that my insurance does not cover.
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