Confidential Patient Information

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Primary Dental Insurance

Secondary Dental Insurance

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Dental History

Medical History

Patients Under 18

PATIENT COOPERATION AGREEMENT

  • 1. CLEAN TEETH AND GUMS: I will brush and floss my teeth and gums properly three (3) times per day, especially after eating meals or snacks.
  • 2. WEARING APPLIANCES: I will wear my headgear, rubber bands or other removable appliances faithfully as directed by the doctor and staff.
  • 3. CARE OF APPLIANCES: I will not eat any foods or get involved in any activities which will damage my appliances and delay my treatment.
  • 4. APPOINTMENTS: I will try to keep all my appointments and arrive on time. I will call as soon as possible if I must change my appointment and always call ahead of time if I have something broken or loose. I will take my fair share of appointments during school hours.