DENTAL INSURANCE(for re-imbursement)
YOU USUALLY SEE A DENTIST:
AT LEAST TWO VISITS A YEARABOUT ONCE EVERY 2-3 YEARSAT LEAST ONCE A YEARONLY WHEN I HAVE A PROBLEM
LAST DENTAL VISIT:
IF YOU COULD CHANGE ANYTHING ABOUT YOUR TEETH, WHAT WOULD IT BE?
VENEREAL DISEASEHEPATITIS OR LIVER DISORDERARTIFICIAL HEART VALVEARTIFICIAL JOINTS/HIPSDIABETESEPILEPSYARTHRITISAIDSCANCERASTHMAGLAUCOMATUBERCULOSISPSYCHIATRIC CAREABNORMAL BLEEDINGBAD BREATHFOOD IMPACTIONSWELLING IN MOUTHUNPLEASANT TASTEAVOID BRUSHING AREAS OF YOUR MOUTHCLENCHING OR GRINDING OF TEETHCOMPLICATIONS FROM EXTRACTIONSFEVER BLISTERS OR COLD SORESHEART TROUBLEPHEUMATIC FEVERHIGH BLOOD PRESSUREHEART MURMURKIDNEY DISORDER
PREGNANTNURSINGON BIRTH CONTROL
I understand and agree that I am financially responsible for all charges, whether or not paid by insurance. I also
agree that I am responsible if my account is placed for collections, which includes but is not limited to interest
charges and attorney fees. I certify that the information that I have provided on both sides of this form is true and
correct to the best of my knowledge. I agree to inform the doctor of any changes in my health status or the above
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