Patient Registration and Health History Patient Details

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Patient Registration and Health History Contact Info

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Telephone (Please fill preferred contact number)

  •  Call
  •  Text
  •  Email

Patient Registration and Health History Emergency Contact Information

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Patient Registration and Health History Responsible Party's Information

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  •  Please check box if the information is same as above. (If so, you can disregard the following section)

Patient Registration and Health History INSURANCE DETAILS

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Patient Registration and Health History Referral Information

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Our Practice Continues to Grow When Our Patients Refer Family and Friends.

Patient Registration and Health History Medical and Dental History Form

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Please indicate your response to the question:

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  •  Yes
  •  No

Please indicate if you have experienced any of the following:

  •  Yes
  •  No
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  •  3 (+) a day
  •  Twice a day
  •  Once a day
  •  Weekly
  •  Seldom
  •  1 (+) a day
  •  2 - 6 weekly
  •  1 - 6 monthly
  •  Seldom
  •  Never

Please indicate your response to the question:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Patient Registration and Health History Authorization

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* The above information is accurate and complete to the best of my knowledge.

* 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.

* I understand that I am financially responsible for all charges whether or not covered by insurance.  As a courtesy this office will file insurance claims. 

* I authorize this office to release information to secure the payment of benefits and I authorize insurance payments to be made directly to this office.

* All accounts will accrue late charges on balances exceeding ninety days. 

* I am aware of and have been offered a copy of the privacy practices in place at this office, (HIPAA Law).

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