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    Patient Information

    MF
    (required)

    Home PhoneWork PhoneCell PhoneE-MailText Msg

    Health Information

    Artificial Heart Valves Artificial Joints AIDS/HIV Asthma Cancer Diabetes Diet Controlled Diabetes Insulin Dependant Diabetes Anemia Epilepsy/Seizures

    Mononucleosis Fainting/Dizziness Convulsions Cardiac Stent Heart Problems Heart Murmur Bladder Problems Hepatitis Cerebral Palsy Measles Tuberculosis Mumps Sinus Problems Blood Disease Drug/Alcohol Abuse Hearing Problems Kidney Disease

    Liver DiseaseThyroid Problems Psychiatric care Stroke Ulcers

    Amoxicillin Allergy Aspirin Allergy Codeine AllergyDental Anesthetics Latex Allergy Penicillin Allergy Tetracycline Allergy Sulfa Drug Allergy Other Drug Allergies

    YesNo

    YesNo
    YesNo
    YesNo

    Dental History

    YesNo
    Well WaterCity WaterBottled Water

    YesNo
    YesNo

    YesNo
    YesNo

    YesNo
    YesNo

    YesNo

    The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services for my minor/child that may be needed 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

    SelfSpouseChildOther

    Secondary

    YesNo

    SelfSpouseChildOther

    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 the medical status of my minor/child. I authorize the dental staff to perform any necessary dental services that my minor/child may need during diagnosis and/or treatment.

    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: