Patient Information Form

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If your dentist has referred you to our office, please fill out our initial contact form. If you don't want to fill it out online, you will be asked to complete the form on your first visit.

(The following confidential information is for our records only)

Please fill out required fields as denoted by *

Health History

I, the undersigned, being the patient, parent or guardian of the above minor patient, consent to the performing of whatever procedure may be determined necessary or advisable, in the opinion of the Doctor. A report of treatment will be sent to my referring dentist. I also understand that upon completion of root canal therapy in this office I will be referred to my general dentist for permanent restoration such as crown, cap jacket, onlay or filling.

I understand that the total payment of the dental service is my responsibility and not that of the insurance company. Payment is due when services are rendered.