Do you have, or have you ever had, any of the following? Please answer ALL questions.
Current medications. (Including prescription, over-the-counter, supplements, vitamins and herbs) If you are currently not taking any medications, supplements, or any natural products, please write NO MEDICATIONS on the first line and sign the bottom.
The undersigned hereby authorizes the Doctor to take 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. 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 my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred. I further understand that a late charge will be added to any overdue balance. I understand that where appropriate, credit reports may be obtained.
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6610 Bryant Irvin, Sutie 100
Fort Worth, Texas 76132
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