New Patient

NEW PATIENT FORM

BOOK AN APPOINTMENT

  • Patient Information

  • (under the age of 18)
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  • Medical Health History

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  • I, the undersigned, certify that I have provided an accurate and complete personal, medical history and have not knowingly omitted any information. Should there be any changes in either my health or any other information I have provided, I will advise this dental hygiene office. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within guidelines of the policy. I understand that responsibility for payment of the dental hygiene services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

    *The Submit button will appear after certify that the information above is accurate.

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