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  • New Patient Form

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  • Who is with the child today?

  • Responsible Party Information

    Applies to minors only
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  • Orthodontic Insurance Information

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  • Emergency Information

  • Dental History

  • Medical History

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  • For women only:

  • Signature

    To the best of my knowledge, all of the preceding answers are true and accurate. If I (or the patient) ever have any change in health status or medications being taken or if I (or the patient) have any abnormal medical test results, I will inform the dentist at the next appointment without fail. I authorize the dental staff to perform the necessary treatment for the purpose of comprehensive filing of insurance claims. I authorize payment of primary insurance benefits directly to the dentist otherwise payable to me. I acknowledge full responsibility for the payment of services at the time of service unless other arrangements are made with this office.
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