Welcome Form

Home / Welcome Form

Patient Information




Guarantor




In case of an emergency, please provide following information:

How you hear about us?


For office use only

I verbally reviewed the medical dental information above with the patient named herein.

Updates

Payment Option


Dental History


Medical History

Have you ever had any of the following diseases or medical problems:


For Women:

Are you taking control pills?
Are you pregnant?

Agreement

I acknowledge that this information is correct and will be held in the strictest confidence. I authorize Jefferson Dental Clinics to contact me regarding promotions and services. I authorize Jefferson Dental Clinics to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. Payment is due in full at the time of treatment unless prior arrangements have been approved. I understand that I am responsible for paying any copayment and deductibles that my insurance soes not cover. I hereby authorize payment directly to Jeferson Dental Clinics of the group insurance benefits otherwise payable to me. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.