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PATIENT REGISTRATION

Maya Dental

Maya Dental 1329 N. Rand Road Palatine,,
Palatine, IL, 60074
(847) 358-9800

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Primary Insurance Information( * mandatory to fill )

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. 

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Medical History( * mandatory to fill )

Although dental personal primary treat the area in and around your mouth , your mouth is part of your entire body. Health problems that you may have or medication thay you may be taking, could have an interrelationship with the dentistry you may receive. Thank you for answering the following questions.

  •  yes
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For woman,

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
Do you have, or have you had, any of the following?
  •  Yes
  •  No
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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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