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Insurance Information

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Dental Information

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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 / gynecologist for assistance regarding additional methods of birth control.


I certify that I have read and I understand the questions above. I will not hold the doctors of Perry Endodontics, P.C. or any other member of their staff, responsible for any errors or omissions that I have made in the completion of this form.

Fees and Payments

All fees are due upon completion of treatment. I hereby authorize payment to Perry Endodontics, P.C. of the benefits otherwise payable to me. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge.

It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to Perry Endodontics, P.C.of the benefits otherwise payable to me.

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

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