• Armin Aliefendic, DDS and Associates

    1710 N. Business 287, Ste #140 Waxahachie, TX 75165

    972-351-9700

  • New Patient Forms - Acquaintance Record

  • We sincerely welcome you and your child into our practice. We will make your dental visits as pleasant as we can. In order for us to better understand your child, please complete this form as thoroughly as possible. Thank you.

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  • DENTAL INSURANCE INFORMATION

  • DENTAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)

  • MEDICAL HISTORY (THIS PORTION OF THE FORM MUST BE COMPLETED)

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  • Person to contact in case of emergency

    (Not living at home)
  • In order to provide your child with optimum care, we draw upon the knowledge of our entire staff of doctors in consultation, diagnosis and treatment of all patients. The undersigned hereby authorizes this dental office to perform the examination and after explanation, the necessary dental services deemed appropriate for the care of the above named child and furthermore, will be responsible for charges incurred from said dental patient.

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