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Patient Information


In case of an emergency, please provide following information:

How did you hear about us?

For office use only

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


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?


I acknowledge that this information is correct and will be held in the strictest confidence. I authorize Now Dentistry to contact me regarding promotions and services. I authorize Now Dentistry 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 does not cover. I hereby authorize payment directly to Now Dentistry 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. I also understand that while visiting Now Dentistry, I will be video taped and recorded by video cameras.