Medical History Dental History Patient Details

Medical History Dental History Contact Information

Medical History Dental History

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well-being. All information with a red (*) must have and answer in the box, if one is not available please put "NO" or "NONE" 

Please mark any of the following to indicate Yes In response to the question: 

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Medical History Dental History

Check if you have had or currently have any of the following: By placing a checkmark I have inclIca:ed Yes. If there is not a checkmark, I have indicated NO 

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Medical History Dental History

  •  To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change In my health, I will inform the office at my next dental appointment without fall.

Medical History Dental History Emergency Contact Information

Medical History Dental History

  •  Yes
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  •  AUTHORIZATION TO RELEASE INFO AND ASSIGNMENT OF BENEFITS

I certify that I ( or my dependant(s) have (has) dental insurance coverage and assign directly to authorize the doctor and/or his staff to release all necessary personal information to my insurance company in order to secure the payment of benefits. I understand that my dental benefit reimbursement plan is an agreement between my insurance company and myself. I further understand that I am responsible for any service fees or balances that may not be covered by my dental benefit plan and any difference resulting from the amount billed, including estimated copayment's already collected, and the amount covered by my plan. 

Authorization 

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. 

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account. 

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by Insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any). 

  •  I hereby certify that I have read and understand the previous information and that It Is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.
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