Patient Information Form

Please correct the errors described below.

Dental History

Medical History

Authorization

I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover. I understand that any schedule changes with less than 48 hours notice may result in charges for time reserved

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.

Dr. Carly Christoferson Petersen, DMD
(503) 636-8446 (Office) 3900 Douglas Way Lake Oswego, OR 97035
https://www.thedentistonboonesferry.com/

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