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Patient Registration Form - Adult

Eau Claire Family Dental

1018 Regis Court,
Eau Claire, WI, 54701
(715) 832-8063

Patient Details( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Insurance Information( * mandatory to fill )
ADDITIONAL INSURANCE INFORMATION( * mandatory to fill )
  •  Yes
  •  No
Emergency Contact Information( * mandatory to fill )
Acknowledgment of Receipt of Notice of Privacy Practices( * mandatory to fill )

I have been given a copy of the Privacy Policy. I understand by signing this form, I am confirming my written permission for the disclosure of my protected health information as described in the Privacy Policy as warranted.

I authorize the release of my information to the specified person(s) involved in my care

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