Patient Updated information Patient Details

Patient Updated information Contact Information

Patient Updated information Primary Insurance Details

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Patient Updated information Health History Updated

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I understand that the information I have given is, to the best of my knowledge, correct and that it will be held in the strictest of confidence.  Because my child is a minor, it is necessary that signed permission is obtained for a parent or legal guardian before any dental services can be rendered.  I understand that during my child’s visit, I must remain at the office until my child is dismissed unless the office has made arrangements with my family.  I give my consent to Dr. Dimock, Dr. Weinberg, Dr. Cherry, and their staff to perform such treatment, services, medication, behavior management techniques, local anesthesia or analgesia to treat any dental/oral deficiency, abnormality and/or infection

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