Yes

1. Patient Information

Yes

2. Phone Numbers

In Case of emergency, contact


3. Dental Insurance


4. Dental History

Check the box if you've had any of the following

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

5. Health History

Yes
Yes
Yes
Yes
Yes

Check the box if you've had any of the following

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes


Allergies

Yes
Yes
Yes
Yes
Yes
Yes
Yes

6. Authorization and Release

I have read and answered the above questions to the best of my knowledge. I authorize the doctor to release all information neccessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance submissions.