Patient Information
INSURANCE INFORMATION
PRIMARY INSURED
SECONDARY INSURED
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PATIENT MEDICAL HISTORY
Your mouth is a integral part of your body. Health problems you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will receive.
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To the best of my knowledge, the questions on this form have been accurately answered. I understand providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
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