Medical History Form




    Primary Insurance Information

    Secondary Insurance Information


    The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Please ask us if you are uncertain about any of the questions. Please fill in the entire form.


    I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

    I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history, and I have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentists to perform previously discussed diagnostic procedures and treatment as may be necessary for dental care. I also understand that consultation with my medical doctor may be required, and I consent my physician being contacted if necessary. I understand that responsibility for payment for dental services provided for myself or my dependants is mine, and I will assume responsibility for fees associated with these services.

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