Are you allergic to, or had a reaction to any of the following:
WARNING: Antibiotics (such as penicillin) may alter the effectiveness
of birth control pills. Consult your physician for assistance regarding
additional methods of birth control.
I have reviewed the information on this questionnaire, and it is accurate
to the best of my knowledge. I understand that this information will be
used by the dentist to help determine appropriate and healthful dental
treatment. It is my responsibility to inform the dental office of any changes
in my medical status and agree to updating my medical history when requested
by the practice.
I authorize the insurance company indicated on this form to pay to the
dentist all insurance benefits otherwise payable to me for services rendered.
I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure
the payment of benefits. I understand that I am financially responsible
for all charges whether or not paid by insurance.
Payment due in full at the time of treatment.