INSURANCE (IF APPLICABLE):
OTHER INSURANCE (IF APPLICABLE):
Please check if the patient has a history of the following medical conditions:
Please check if the patient has, or ever had, any of the following habits?
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.
I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient.
I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
By submitting this form you agree to the above mentioned consent statement
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