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    Patient Information

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    Health Information

    Artificial Heart Valves Artificial Joints AIDS/HIV Asthma Cancer Diabetes Diet Controlled Diabetes Insulin Dependant Diabetes Anemia Epilepsy/Seizures Emphysema
    Fainting/Dizziness Heart Attack Cardiac Stent Heart Problems Pacemaker Hemophilia/Bleeding Disorder Hepatitis High Blood Pressure Low Blood Pressure Tuberculosis Arthritis/Rheumatism Back Problems Blood Disease Drug/Alcohol Abuse Cocaine Use
    Cortisone Treatments Glaucoma Kidney Disease Liver Disease Psychiatric Care Stroke Thyroid Problems Ulcer(s) Headaches Snore/Sleep Apnea Venereal Disease Amoxicillin Allergy Aspirin Allergy Codeine Allergy
    Dental Anesthetics Latex Allergy Penicillin Allergy Tetracycline Allergy Sulfa Drug Allergy Other Drug Allergies

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    It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and/or treatment.

    In lieu of signature please place the first letter of the city you were born in:

    Date:

    Person Responsible For Payment

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    Credit Card Authorization (optional)

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    Insurance Information

    Primary

    YesNo

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    Secondary

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    Consent for Services

    I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions whether manual or electronic.

    I authorize the dentist to release all information necessary to secure payment of benefits.

    A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

    It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services.

    I have received a copy of the Notice of Privacy Practices of Michele S. Horton, D.D.S.,FAGD , PC and have been given an option to opt out.

    I have read the above conditions of treatment and payment and agree to their content.

    In lieu of signature please place the first letter of the city you were born in: