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Prairie Dental Group

6608 Flying Cloud Drive,
Eden Prairie, MN, 55344
(952) 903-5000

Patient Details( * mandatory to fill )

WELCOME! Our goal is to help you have the healthiest, brightest smile possible. Please provide the following information as completely as you can. The better we communicate, the better we can care for your dental needs.

  •  email/text
  •  phone call only
  •  email only
  •  text only
Account Information( * mandatory to fill )
Primary Dental Insurance( * mandatory to fill )

I authorize the administration of such medications and performance of such diagnostic and therapeutic procedures as may be necessary for proper dental care. If additional information is needed, I authorize this office to contact the appropriate health care provider or agency to obtain such information. I understand that dental insurance is a contract between the policyholder and the insurance carrier, and that I am responsible for payment of fees for services not covered in part or in whole by the insurance carrier. I authorize payment of dental insurance benefits directly to this office. The above information is correct to the best of my knowledge. Charges may be assessed if less than 48 hours notice or no notice is given when an appointment cannot be kept.

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(Your IP Address : IP:34.236.153.51 )
Secondary Dental Insurance( * mandatory to fill )
( * mandatory to fill )

I authorize the administration of such medications and performance of such diagnostic and therapeutic procedures as may be necessary for proper dental care. If additional information is needed, I authorize this office to contact the appropriate health care provider or agency to obtain such information. I understand that dental insurance is a contract between the policyholder and the insurance carrier, and that I am responsible for payment of fees for services not covered in part or in whole by the insurance carrier. I authorize payment of dental insurance benefits directly to this office. The above information is correct to the best of my knowledge. Charges may be assessed if less than 48 hours notice or no notice is given when an appointment cannot be kept.

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(Your IP Address : IP:34.236.153.51 )
MEDICAL HISTORY( * mandatory to fill )

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 have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
( * mandatory to fill )
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