New Patient Heath History Form

Pediatric & Adolescent Dentistry and Orthodontics

Please correct the errors described below.

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HEALTH QUESTIONNAIRE

I hereby certify the foregoing information is true and correct. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

CONSENT-RESPONSIBILITY

  1. I authorize the specialist to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with my child. I understand that using anesthetics agents embodies a certain risk. Furthermore, I authorize and consent that the specialist choose and employ such assistance as deemed fit to provide recommended treatment.
  2. I understand that all responsibility for payment for dental services provided in this office to my child, due and payable at the time services are rendered unless other arrangements have been made. In the event payment are not received by the agreed upon dates, I understand that a 1-1/2% finance charge (18% APR) may be added to my account.
  3. I understand that where appropriate, credit bureau reports may be obtained.
  4. I authorize the use of my social security number to file my child's dental claim.

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

Your information will be encrypted.