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  • Please take a moment to let us know about your medical and dental history so we may serve you in a way that takes into consideration your overall health and well-being.
  • DD slash MM slash YYYY
  • IN CASE OF EMERGENCY

  • PARENT/GUARDIAN/CAREGIVER 1 INFORMATION:

  • PARENT/GUARDIAN/CAREGIVER 2 INFORMATION:

    (IF DIFFERENT THAN ABOVE)
  • PLEASE LIST ANY OTHER PERSONS WHO MAY HAVE ACCESS TO THIS FILE

    (E.G. SCHEDULING APPOINTMENTS)
  • INSURANCE INFORMATION

  • IF THE PATIENT HAS A DENTAL PLAN, PLEASE COMPLETE THE FOLLOWING
  • PATIENT DENTAL HISTORY

  • MEDICAL HISTORY (PLEASE SELECT YES OR NO TO EACH QUESTION)

  • If yes, please provide details:
  • If yes, please explain:
  • If yes, please explain:
  • If yes, please explain:
  • If yes, please provide details:
  • If yes, please list and provide reason for taking:
  • Medications
  • Latex/rubber derived products
  • Other (e.g. seasonal, foods, dyes)
  • If yes, please explain:
  • If yes, please explain:
  • If yes, please explain:
  • If yes, please provide details
  • If yes, please explain:
  • If yes, what is the expected delivery date:
  • If yes, please explain:
  • If so, please advise:
  • I hereby certify that I have read and understand the previous information and that it is true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. I will keep the dental office updated with any changes to my health and/or medications and allergies.

    Authorization

    I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. Privacy of our patient’s personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft, and unauthorized access.

    Personal information for our purposes is; that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes clinical records, x-rays, study models, photographs of your teeth, mouth, smile, face, and general health information obtained from a medical history review, insurance information, phone numbers and addresses. Clinical information, photographs and x-rays may also be used for long-term follow-up, research purposes, anonymously on our website smile gallery, as well as for education or teaching purposes.

    Your personal information shall be disclosed to only those who have a need to know and specific information. Disclosed shall be restricted to only that information relevant to what the recipients need to know. Those who have a need to know include referring dentist, other dental specialists, physicians, dental laboratories, and dental insurance companies. The security and privacy of your personal information is one of our primary concerns and we have taken every precaution to protect it.

    I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any).


    I am also aware of the cancellation policy of True Dental. 48 hours notice for cancellation of appointments is required in which case no charge will be made. Short notice and no show appointments will be charged at $50.00 per half hour. Please call the office and speak with a team member to reschedule.

    Signature of patient, parent, or guardian: