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Patient Information

First Name.
Last Name.
Street Adress
Postal Code
(under the age of 18)


Medical Health History

Street Address
Postal Code
In case of emergency, please contact this person.
(Please check any that apply)

Please add anything else you would like us to know about:

I, the undersigned, certify that I have provided an accurate and complete personal, medical history and have not knowingly omitted any information. Should there be any changes in either my health or any other information I have provided, I will advise this dental hygiene office. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within guidelines of the policy. I understand that responsibility for payment of the dental hygiene services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

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