• RHODE ISLAND PERIODONTICS

    Health History

  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  

  •  
  • Emergency Contact:

  •  -
  •  -
  •  -
  • General Consent to Treatment:

    I agree and consent to a dental examination and understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatment performed.

    Release of Information:

    I authorize Dr. Katz, Theberge, Coleman and Pham to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.

    Acknowledgement of Receipt of Notice of Privacy:

    I have received a copy of this office's Notice of Privacy Practices

    Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally incapable.

    I hereby state that the above health questionnaire has been answered to the best of my knowledge.

    I authorize the release of information.

    I understand and agree to the General Consent to Treatment.

    I acknowledge receipt of notice of privacy.

  • Clear
  •  -  -
    Pick a Date
  • Clear
  •  -  -
    Pick a Date
  • Should be Empty: