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Who may we thank for referring you
If female, are you pregnant or nursing:
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Are you allergic to any of the following:
I understand that the information I have given is correct to the best of my knowledge and will notify office of any changes. I authorize dental staff to perform any necessary dental services for my treatment. If the office accepts my insurance, I understand that the office will file insurance and use my signature on all insurance submissions. I am responsible for payment of services rendered, any co-payments and deductibles that my insurance does not cover at the time of service. I hereby assign payment to the dental office and the release of any information necessary to my Insurance company
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