PATIENT INFORMATION

First
Middle
Last
Nickname
Street
City
Zip

RESPONSIBLE PARTY INFORMATION

Street
City
Zip
Street
City
Zip
City
First
Middle
Last
Street
City
Zip
Street
City
Zip

DENTAL INSURANCE INFORMATION

EMERGENCY INFORMATION

Street
Street
Zip

MEDICAL HISTORY

DENTAL HISTORY

AIRWAY EVALUATION

BENEFITS

Jeffrey H. Wong, D.D.S., M.S.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**


Jeffrey H. Wong, D.D.S., M.S.

NOTICE OF PRIVACY PRACTICES