• Medical and Dental Health History Form

    Medical and Dental Health History Form

  • Curtis E. Hahn, D.D.S. 4992 Wilson Avenue | Grandville, MI 49418 616.534.0135 | rivertowndental.com

    Please fill out the electronic form below. Alternatively, you can view / download / print our form for manual submission using the link below.

    Medical & Dental Health History

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  • Authorization

  • I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

    I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

    I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.

    I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

    I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

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  • Everyone deserves a healthy smile!

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