Patient History

Patient History

  • First Middle Last
  • Patient name
  • Dental Insurance Info

  • Medical History

  • Dental History

    Circle all that apply
  • Authorization and Release

  • In accordance with the Privacy Rules of HIPAA and with my understanding of the Patient Notice that I have read, I am hereby giving my full consent to Shepherd Mall Family Dentistry to maintain my medical/dental records, transmit, forward and or release information about me, my health information and/or my Personal Health Information to any applicable person(s) or agencies, provided it is in my best interest and/or for the advancement or continuance of any health care services which I am being treated. I have read and answered the above questions to the best of my knowledge. I understand that I am ultimately financially responsible for all charges. By signing below I acknowledge my understanding of all terms and conditions.
  • ~ We are happy to assist you with your insurance; however, your co-pay is due the day services are rendered ~

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