• Health History Form

    Health History Form

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    Pick a Date
  • Responsible Party Information

    (Person responsible for paying the account)
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    Pick a Date
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  • Patient Dental Information

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  • Patient Medical Information

  • Patient General Information

  • Emergency Contact

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  • Photo Permission

  • Notice of Privacy Practices Acknowledgement

    * You May Refuse to Sign This Acknowledgment*
  • HIPAA Access

    Due to the HIPAA Privacy Rule, we must have permission for any other person to have access to the account/healthcare records.
  • Please list below the names of the people who are allowed access to the above named account, including yourself, biological parents, step-parents, grandparents, if applicable.

  • Signature

  • Clear
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  • Should be Empty: