Patient Registration Form

Please correct the errors described below.

Thank you for choosing our office. In order to serve you properly, please answer all questions on BOTH sides, so that we may diagnose your oral health as accurately as possible. All information will be kept strictly confidential.

IN CASE OF EMERGENCY, WHOM MAY WE CONTACT? (Other than someone living with you)

Payment Is Expected At Time Of Each Visit

Primary Dental Insurance

Secondary Dental Insurance

CONSENT TO TREATMENT

I grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health History form, to administer upon explanation such anesthetics, analgesics, sedatives, nitrous oxide sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I grant my permission to you, or your assigns, to telephone me at home or at my work to discuss matters related to 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.

MEDICAL HISTORY

DENTAL HISTORY

I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

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.

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