Patient Information Sheet Logo
  • Harry Ringer D.D.S.
    Family & Cosmetic Dentistry

  • 1530 Baker Street, Suite F
    Costa Mesa, CA 92626
    ☎️ Voice: 714-545-4958
    FAX: 714-276-0691
    http://www.drringer.com
    E-Mail: info@drringer.com

  • Patient Information Sheet

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  • Dental Insurance Information

  • I hereby grant authority to HARRY RINGER, D.D.S., and/or to the dentist(s) in charge of my care, to administer any treatment, to administer such anesthetics; and to perform such operations as may be deemed necessary in the diagnosis and treatment of my case. I authorize the taking of radiographs, photographs, or other diagnostic aids as needed for a thorough evaluation.

    I acknowledge that I have been informed of the risks and possible consequences of the operation/s proposed and do authorize the above-named doctor(s) to proceed, and will assume financial responsibility.

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  • Patient or legal guardian in the case when the patient is a minor or physically or mentally incompetent.

  • Health History

  • NOTE: If prescribed antibiotics, there is the potential that your birth control’s function may be effected.
    To the best of my know/edge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicines change, I will inform the doctor of dentistry at the next appointment without fail.

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  • Medications

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  • Personalized Esthetic Evaluation

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  • Please answer the following questions that are specifically designed to aid our diagnosis and treatment of your esthetic needs:

  • Should be Empty: