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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Do you have, or have you had, any of the following?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
With the recent advancement in materials and techniques, many of our patients are asking more questions about cosmetic dental procedures. In order to better serve you, please take a moment and let us know how you feel about the appearance of your smile.
Our commitment is to provide quality dental care to the entire family through exceptional service and the utilization of advanced technology.
I have read and understand that above information. I understand I am responsible (regardless of my insurance) for any charges incurred for services rendered.
On this date, the Notice of Privacy Policy form was delivered. The form was not signed due to:
