Patient Registration Form

PATIENT INFORMATION

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DENTAL HISTORY

MEDICAL HISTORY

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(You may also call and provide your SS# at (919) 518-8222)

PLEASE INFORM THE DOCTOR IF YOUR HEALTH CHANGES IN ANY WAY

MEDICAL HISTORY CONTINUED

FOR WOMEN ONLY

Acknowledgement of receipt of Notice of Privacy Practices

*You may refuse to sign this acknowledgement*

CONSENT FOR TREATMENT

2. Upon such diagnosis, I authorize North Raleigh Periodontics to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

4. Lastly, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR ) may be added to my account.

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