Welcome to our Practice

Sein H. Siao D.M.D. and Associates

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PATIENT INFORMATION

Responsible Party

(If self, skip to next section)

INSURANCE INFORMATION

Primary Dental Insurance Company

Secondary Dental Insurance Company

Permission for Dental Examination and Treatment

I do hereby authorize and consent to any x-rays, examination, anesthetic, or dental treatment rendered under the general, direct, or indirect supervision of Dr. Siao and/or staff members they may deem necessary. This authorization will remain in effect until cancelled in writing by me. 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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