Patient Information Patient Details

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Thank you for visiting Moore Family Dentistry. We want your visit to be pleasant and comfortable. Please help us by completing this form.

Patient Information Contact Information

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Patient Information Emergency Contact Information

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Patient Information Primary Insurance Details

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Insurance Authorization Statement

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs and dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary or proper dental care. The information on this page and the medical history is correct to the best of my knowledge.

Patient Information Responsible Party's Information

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If Patient is Under 18

Patient Information Other Information

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Patient Information Authorization

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