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Patient Information

Responsible Party Information

Primary Insurance Information

Secondary Insurance Information

Dental Information

Medical Information

ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO:
WOMEN ONLY, ARE YOU:
PLEASE MARK YOUR RESPONSE TO INDICATE IF YOU HAVE OR HAVE NOT HAD ANY OF THE FOLLOWING DISEASES OR PROBLEMS:
Except for the conditions listed above, antibiotics prophylaxis is no longer recommended for any other form of CHD.
PLEASE MARK YOUR RESPONSE TO INDICATE IF YOU HAVE OR HAVE NOT HAD ANY OF THE FOLLOWING DISEASES:
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

AUTHORIZATION

I certify that I have read and understand the above 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 authorize the dentist to release any information including the diagnosis and the records of any treatment and examinations rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for the payment of all services rendered on my behalf or my dependents.