Patient Information Patient Details

Patient Information Contact Information

  •  Email
  •  Text Message
  •  Both

Patient Information Responsible Party's Information

Patient Information Emergency Contact Information

Patient Information Primary Insurance Details

Patient Information Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could h
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  •  Pregnant/trying to get pregnant?
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  •  Local anesthetics
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Do you have, or have you had, any of the following?
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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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Patient Information Cancellation Policy

Our desire is to provide you with the highest quality service and exceptional dental care in a caring and enjoyable atmosphere. We value your time and strive to maintain your appointment at the allotted time, in return, we request the same from you. We will need at least 24 HOURS notice to cancel or reschedule an appointment.

Unfortunately, as a result of the significant increase in short notice cancellations and disregard for appointment confirmations, it has become necessary for us to enforce the following policy.

Failure to provide adequate notice may result in the following:

  •  If you are more than5-7 minutes late for your appointment, it may be necessary for you to be reschedule and that appointment could be considered a cancellation without adequate notice. PLEASE call if you feel you may arrive later than your scheduled appointment time so that our team can make accommodations to see you.
  •  a $25.00 fee MAY be accessed to your account and must be paid before being rescheduled.
  •  Single patient scheduling, only one family member scheduled at a time, If multiple appointments are failed within the same day.
  •  As a last resort and after MANY failed attempts to schedule appointments, we may have no choice but to dismiss your care from the practice.

**Thank you for your understanding that we are committed to being available to ALL our patients who need dental care.

** I HAVE READ AND UNDERSTAND THE POLICIES ABOVE:

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Patient Information Receipt of Notice of Privacy Policies

Your Privacy Is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

I have received a copy of the Notice of Privacy Practices of M Skidmore D.D.S. I hereby authorize, as indicated by my signature below, to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

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(Your IP Address :IP:18.234.247.75 )
  •  You may contact me at my home telephone number
  •  You may contact me on my mobile telephone number
  •  You may contact me on my work telephone number
  •  You may send me an email at
  •  Other

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

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