New Patient Forms

Please correct the errors described below.

Person Responsible for Payment

Primary Dental Insurance

Secondary Dental Insurance

Person to Contact in Case of Emergency

I/We Authorize the release of any medical information necessary to process my claim. I/We request that any payment of insurance benefits be paid to Aziz A. Majid DMD, MSD, PC. I/We also understand that if for any reason, the insurance company doesn't pay for services, or if they only provide partial payment that I/We will be responsible for the same. I/We agree 1 1/2 % interest per month on any outstanding balance and attorney Fees.

Before treatment can begin, this agreement must be signed by the dental insurance holder as the responsible person, along with the patient, in the event that patient is not also the dental insurance contract holder.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT MEDICAL HISTORY

Check any of the following that you are taking or have taken:

If female, please answer the following:

Please answer the following:

For Office Use Only

Conditions

Allergies

DENTAL HISTORY

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