New Patient Form

Please correct the errors described below.

Primary Dental Insurance Coverage

Secondary Dental Insurance Coverage

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 Dr. Aziz A. Majid D.M.D.;M.S.D. 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.

Health History

Dental History

I consent to whatever Dental Procedures and anesthetics for the treatment of the above named patient. I also agree to full Financial Responsibility for all treatment rendered.

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 Information

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