CONFIDENTIAL PATIENT INFORMATION
INSURANCE INFORMATION
EMERGENCY CONTACT INFORMATION
DENTAL HISTORY
Date of Last Visit:
MEDICAL HISTORY
DOES THE PATIENT NOW, OR HAVE THEY EVER HAD ANY OF THE FOLLOWING?
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION NOT DISCLOSED. I understand that when appropriate a credit report may be obtained.
ACKNOWLEDGEMENT OF HIPPA PRIVACY PRACTICES
*You May Refuse to Sign This Acknowledgement*
understand the Notice of HIPPA/Privacy Practices
(Copy of HIPPA form available on request)