New Patient Registration

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Patient Information

Patient Dental History

Responsible Party Information

(If different from Section 1)

Insurance Information

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Emergency Information

Patient Medical History


Drugs & Medications

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By signing, I agree that the information I have given today is correct to the best of my knowledge. I also understand that this information is held in the strictest confidence, as described in the Notice of Privacy Practices given to me. I recognize that it is my responsibility to inform this office of any changes in my medical status. I understand that when appropriate, credit bureau reports may be obtained. Furthermore, I authorize this staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

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