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  • Responsible Party

  • Patient Info

  • Primary Insurance

  • Medical History

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Women

  • Are you allergic to any of the following?

  • Do you have or have you had any of the following?

  • How did you hear about us?