Registration Form - Adult

Please correct the errors described below.

REGISTRATION

Children:

If you checked "Self", please skip next section and continue with insurance section.

PERSON RESPONSIBLE FOR THIS ACCOUNT OTHER THAN ABOVE NAMED PATIENT

FOR PATIENTS COVERED BY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

MEDICAL HISTORY

For your health's sake, please be accurate -

10. Circle any of the following which you have had or have at present:

DENTAL HISTORY

If other than NONE, please specify
If other than NONE, please specify
If other than NONE, please specify

To the best of my knowledge, all of the preceding answers are true and correct. lf I ever have any change in my health, or if my medicines change, I will inform the dentist at the start of the next appointment.

Also, the undersigned hereby authorizes the taking of x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs (after discussing these with the patient). I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this otfice for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I understand the office may request information from, or report information to a credit rating institution.

For Office Use Only (Do not fill out)

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