Patient Registration

Please correct the errors described below.

HIGH COUNTRY DENTAL

303-693-5600

20250 E Smoky Hill Rd #3, Centennial CO 80015

Primary Insurance

Secondary Insurance

Dental History

To serve you properly we will need the following information. All information will be strictly confidential.

Indicate which of the following you have at the present. Choose Yes or No for each item.

Mouth

Teeth

Medical History

(Women Only)

Indicate which of the following you have at the present. Choose Yes or No for each item.

Consent

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand the use of anesthetic agents embodies a certain risk.

I authorize the Doctor to release my information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I assign all benefits to the Doctor and request the insurance company pay the dentist directly.

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.

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