Responsible Party (if someone other than the patient)

Dental Insurance Information 

If new please provide.

Payment is due at the time services are rendered.
If you have dental insurance we will process your claims, but you are responsible for the estimated portion at the time ofservices.

24 hour notice is required ifyou are unable to keep an appointment.

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I/We agree to contact Willhite Family Dentistry if I/we develop any symptoms of COVID-19 in the next 14 days.

I agree the above statements are true and correct to the best of my knowledge.

WILLHITE FAMILY DENTISTRY

Notice of Privacy Practices Acknowledgement of Receipt Form

I hereby acknowledge I have received а сору of the Notice of Privacy Practices for WILLHITE FAMILY DENTISTRY.

Or