Patient Information & Health History

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APPOINTMENTS: A minimum charge will be made for failed or canceled appointments without prior notification of 24 hours. This covers only a portion of the overhead such as salaries, electric, heat, etc.. which still has to be paid whether you are present or not. Once an appointment is made, please remember this time has been reserved for you.
INSURANCE: To avoid misunderstandings regarding dental insurance, we wish our patients to know that all professional services rendered are charged directly to the patient and that patients are personally responsible for the payment of fees. We will prepare necessary forms or reports to help you obtain your benefits from insurance companies, upon receipt of full (or partial) payment of the bill. We do not render our services on the basis that insurance companies will pay all our fees. Each fee is individual for the individual patient.

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Parent or Guardian (If patient is minor)

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