Patient Information
Responsible Party (if someone other than the patient)
Primary Insurance Information
Secondary Insurance Information
Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is 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.

Women: Are you...
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
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