Patient Information

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GENERAL INFORMATION

ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY:

I UNDERSTAND I AM FULLY RESPONSIBLE AND LIABLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE PLAN (IF APPLICABLE). I AGREE TO PAY A CANCELLATION FEE OF A MINIMUM CHARGE OF $25 IF I CANCEL AN APPOINTMENT WITH LESS THAN 24 HOURS' NOTICE.

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.

RELEASE OF CONFIDENTIAL MEDICAL INFORMATION:

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.

PATIENT REGISTRATION

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Responsible Party (if someone other than patient)

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Preferred Pharmacy

Primary Dental Insurance Information(if applicable)

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Secondary Dental Insurance Information (If applicable)

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