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CONFIDENTIAL

Medical Dental History Form for Patients Under Age 18

PATIENT

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

PATIENT HEALTH INFORMATION

MEDICAL HISTORY

MEDICAL HISTORY continued

DENTAL HISTORY

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Parent/Guardian Signature

Parent/Guardian Signature

Arthur B. Silver,DDS,PC,Snellville, GA 30078 770 972-6000

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

SIGNATURE

Signature

REVOCATION OF CONSENT

Signature

Arthur B. Silver, DDS, PC, Snellville, GA 30078 770 972-6000

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

** You May Refuse to Sign This Acknowledgement **







Signature of Responsible Party


Release Authorizing Use of Personal Likeness


Patient/Guardian Signature:


Provider signature:

Insurance Card
Drivers License