• Patient Info, Medical & Dental History

    Patient Info, Medical & Dental History

    Smile Experts Dental, 9570-A Burke Road, Burke, VA 22015
    • PERSONAL 
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    • ADDRESS AND HOME PHONE 
    • EMERGENCY CONTACT INFORMATION 
    • INSURANCE POLICY 1 
    • Please present insurance card to receptionist.

    • Medical History 
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    • Dental History 
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    • On a scale of 1 (low/not important) to 5 (high/very important) please rate the following:

    • The information entered above is true to the best of my knowledge. I understand that incorrect information or omission of information can be dangerous in case of an in-office emergency or otherwise. If the patient is a minor, permission is hereby given for dental treatment as deemed necessary to be performed in our office or until written notice is given discontinuing this permission. I agree to be financially responsible for all expenses incurred for myself or my dependents.

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