Medical History

Please correct the errors described below.

Health History Form

For the following questions, please (X) whichever applies, your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Dental Information

Medical Information

If you answer yes to any of the 3 items below. Please stop and contact the receptionist.

Physician

If yes, which drug are you taking?

Women Only

Note: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above, I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist or any other member of his/her staff , responsible f or any ac ti on they take or do not take because of errors or omissions that I may have made of the competition of this form.

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

TMJ - Occlusal Examination

Dental Insurance

Assignment and Release

I, the undersigned, certify that I (or my dependents) have insurance coverage with the dental insurance company listed above and assign directly to Dr. Tzioros all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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

Your information will be encrypted.

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