Patient Health History

Patient Medical History

Patient Dental History

Authorization and Release

I certify that I have read and understood the above information to the best of my knowledge. The above questions have been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the oral surgeon to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental/medical care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the oral surgeon or practice, insurance benefits otherwise payable to me. I understand that my dental/medical insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of myself or my dependents.

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.