Medical History Patient Details

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Medical History Medical History

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Do you have or have you had any of the following: (Check Yes or No)

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Medications 

Allergies

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Medical History Signature

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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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