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Welcome !!!! Thank you for selecting our office for your dental care. Please fill out this form as completely as possible. Today’s Date____________ Name_________________________________ SS#________________Birthdate___________ Home Phone#________________Work Phone#__________ Address:____________________City:__________Zip_____ Please circle: Minor Single Married Divorced Widowed Patient’s Employer_________________________________ Spouse’s Name or Parent’s Name if Child________________ Whom May We Thank For Referring You?________________ Person to Contact in Case of Emergency________________ Phone #_____________________ Name of Person Responsible for this Account_____________ We offer the following methods of payment for your visit. Please circle which you prefer. Payment is due at the time of your visit . Cash Check MC/Visa American Express Discover Thank you |
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