Please take a moment to let us know about your medical and dental history so we may serve you more effectively.
Please check any of the following that may apply to you:
How many time a day do you brush?
Family Physician Information:
Have you ever had complications following medical treatment?
On a scale of 1-10, how important is your dental health?
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
I understand that I am financially responsible for services rendered to me or to my dependents that are not fully covered by my
insurance (if applicable) and I may be billed for this remaining balance. I agree to pay all uninsured services or insurance
differences at the time services are performed, unless other arrangements are made.
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