New Patient Registration

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  • MEDICAL HISTORY QUESTIONNAIRE

    Answer each question below as best you can.



  • DENTAL HISTORY QUESTIONNAIRE

    Answer each question below as best you can.
  • GENERAL RELEASE / INFORMED CONSENT

    I, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history. I have not knowingly omitted any information. Should there be any changes in my health status, in the future I will inform this dental office. I understand that the use of medication and anaesthetic agents embodies a certain risk and that consultation with other health care providers may be required prior to treatment. Therefore, I consent to the release of this medical information as deemed necessary for consultation purposes only.

    I understand that it is required that I give at least 48 hours notice if I have to reschedule an appointment. If I fail to give sufficient notice I understand I will be charged $50.00 and will be required to place a deposit in order to schedule another appointment. I understand that responsibility for payment of services is mine and that payment in full is due and payable at the time treatment is rendered.
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