Patient Medical Dental History

Please correct the errors described below.

Please answer the following question so that we may provide better dental care for you

4. Do you have or have you ever had: (If you need help answering these questions, tell us.)

If female, Please answer the following:

Consent For Dental Treatment

Permission is hereby granted to examine the listed patient, administer anesthetics and to employ such operative or technical procedures as may be deemed necessary or advisable in the diagnosis or treatment of the dental condition of the patient.

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if any medicines, I will inform the dentist at the next appointment without fail.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Who is financially responsible for dental bill?

I understand that Hampton Dental Group, P.C. is not a participating provider with any dental plan/insurance company /benefit fund, Medicaid, etc. and that I am financially responsible for my dental bill.

As a courtesy to our patients, Hampton Dental Group, P.C. will attempt to maximize your dental plan's coverage as long as your plan allows the option for out-of-network providers.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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