• New Patient Paperwork for Adults

    Welcome to Palmetto Smiles! Please fill out all pages on this form to the best of your ability so that we may prepare for your first appointment.
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  • Person Responsible For Financials

    If you are the person responsible, you may mark self and skip the rest of the page.
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  • Person To Contact In Case Of Emergency

    Outside immediate family
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  • Consent For Dental Consultation And Radiographs

    A dental radiograph (x-ray) examination is one of the most important diagnostic tools your dentist uses to determine the presence of any dental disease and help you prevent dental diseases. Dental films enable the dentist to see inside bone and into the spaces between your teeth where even the smallest instrument cannot probe. Despite the preventative measures taken today by conscientious dentists and patients, problems can still develop in and around your teeth and supporting bone. You want the best possible care. Your dentist can give you the best care only with the help of a dental radiographic examination. With the aid of dental films, your dentist can often detect conditions that, if left untreated, would eventually affect the function and appearance of your teeth as well as your overall health.
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  • Medical History






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  • Dental History

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  • Primary Dental Insurance Only

    Please note we are not a participating or contracted provider with any insurance plan. We will verify your orthodontic benefit for you prior to your consultation.
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  • Office Policies

    Please click the link, review our office policies and sign below to indicate you have read and understand our policies.
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  • Acknowledgement of Receipt of Notice of Privacy Practices

    You may refuse to sign this acknowledgement. Please click the link, read and sign below to indicate you have read and understand the Notice of Privacy Practices.
  • I, , have received a copy of this office's Notice of Privacy Practices.

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  • Authorization Compound

    This authorization form permits Palmetto Smiles 139 Whiteford Way Lexington, SC 29072 to use or disclose protected health information listed in the description sections below to the Entity or Person listed in each section.
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