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Who will be responsible for your account?

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health History

Have you had or do you currently have the following:


Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following:

For Women Only

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's health. It is my responsibility to inform the dental office of any changes in medical status

If Patient is a Minor


Online Signature×
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