It is the goal of our office to provide you a quality of care of the highest standards. Your comfort during your treatment is important to us. Please fill out this with the best of your knowledge.
If activated, a guardian or DPOA representative needs to be present for the appointment as well as the paperwork is required by our office prior to your scheduled visit - please call our office with any questions.
If patient is a minor or is under guardianship:
Please List Your:
To minimize our fees to you for treatment, we expect payment at the time of treatment. Patients with insurances may be requested to make co-payment at the time of treatment. Visa, MasterCard, and Discover are accepted. These policies will be adhered to unless arrangements with our office are made in advance of treatment.
A detailed health history is invaluable for helping us treat you safely and effectively. Please be very accurate in the following sections. The confidentiality of this medical record is assured.
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