CONFIDENTIAL PATIENT INFORMATION

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SPOUSE OR RESPONSIBLE PARTY INFORMATION

REFERRAL INFORMATION

HEALTH INFORMATION

DENTAL HISTORY

Have you had any of the following? Please check those that apply:

TO THE BEST OF MY KNOWLEDGE, ALL OF THE INFORMATION I ENTERED ABOVE IS TRUE AND CORRECT. IF THERE IS ANY CHANGE IN MY HEALTH OR MY MEDICATIONS, I WILL INFORM THE DOCTOR PRIOR TO ANY TREATMENT.

 

I AUTHORIZE THE DOCTOR AND/OR THEIR STAFF TO TREAT THE ABOVE NAMED PATIENT. I WILL CONTACT THE DOCTOR OFFICE IF I HAVE ANY ADDITIONAL QUESTIONS OR THERE ARE ANY UNEXPECTED REACTIONS TO TREATMENT. I REALIZE THAT THE RESULTS OF CERTAIN PROCEDURES CANNOT BE GUARANTEED.

 

ALL FINANCIAL ARRANGEMENTS WILL BE MADE PRIOR TO TREATMENT. I REALIZE THAT, ULTIMATELY, I AM COMPLETELY RESPONSIBLE FOR PAYMENT OF ALL TREATMENT. THE OFFICE WILL ASSIST BY FILLING ALL NECESSARY INSURANCE PAPERWORK.

 

I REALIZE THAT THE FEE ESTIMATE LISTED FOR DENTAL CARE IS VALID FOR ONLY SIX MONTHS.

 

I HAVE READ AND FULLY UNDERSTAND THE CONDITIONS OF TREATMENT S STATED.

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