• PATIENT REGISTRATION AND MEDICAL HISTORY

    (Please Print)
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  • MEDICAL HISTORY

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  • Have you ever had any of the following? (Check all _✔_ that apply.)

  • (If yes, please list on the next page provided.)

  • The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing & processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

  • Clear
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  • Assignment and Release

  • I, the undersigned, have insurance with and assign directly to Dr. Eric J. Sadler, DDS, PA and Dr. David R.J. Plummer, DDS, PA all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

  • Clear
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  • MINOR/CHILD CONSENT

  • I, being the parent or guardian of fdo hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the provider, whether or not I am present at the actual appointment when the treatment is rendered.

  • Clear
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  • FINANCIAL AGREEMENT

  • I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance.

  • Clear
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  • Should be Empty: