Is the event of an emergency, is there someone who lives near you that we should contact?
Have you ever had any of the following diseases or medical problems?
Are you allergic to any of the following?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
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Payment is due in full at time of treatment unless prior arrangements have been approved.
Thank you for filling out this form completely. It will enable us to help you more effectively. If you have a question at any time, please ask us. we are happy to help.
Our office is HIPAA compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.