New Patient Form

To the best of my knowledge, all of the preceding information is true and correct. If there is a change to my health, I will inform the office at my next dental appointment without fail. I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing false and/or incorrect information may be hazardous to my health. I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance.