Schedule Your Appointment in Bethesda, MD

Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

Patient Information

 
 
 
 
Phones
 
 
 
 
 
Sex:
 
 
 
Marital Status:
 
 
 

Responsible Party Information

 
 
 
 
Phones
 
 
 
 

Dental Insurance Information

 
(If yes, please complete the following:)
 
 
 
 
Phones
 
 
 
 
 
(If yes, please complete the following:)
 
 
 
 
Phones
 
 
 
 

INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT

I understand that I am financially responsible for all charges whether or not paid by insurance. I assign all insurance benefits directly to the doctor otherwise payable to me for services rendered. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
 

Medical History

Please check the box if you have ever had any of the following:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart Problems:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Allergies:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Women:
Are you pregnant?
Are you nursing?
 
Medications: Please list medications you are currently taking and why
 

Dental History (New Patients Only)

 
Checkmark if you have ever had any of the following:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Checkmark if you have ever had any of the following:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

TREATMENT AUTHORIZATION

I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.
 
 
 
 
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