• Patient Health History

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  • Medical History

    Please fill out this form as complete as possible.
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  • Dental History

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  • Authorization & Release

  • I have read and answered the above questions to the best of my knowledge.  I authorize the doctor and his representatives to release all information necessary to assist in securing the payment of my dental benefits.  I understand I am financially responsible for all charges whether or not paid by my insurance.  I authorize the use of this signature on all insurance claims.

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  • Should be Empty: