WELCOME! AMADOR FAMILY DENTISTRY, PLLC
Patient Registration & Health Record (front & back)
In order to render the proper dental services, to you, would you please be kind enough to answer the following questions. Thank you for your cooperation.
Have you ever been treated for or do you currently have :
Medical review (for the doctor’s use only)
Dental History
By signing this questionnaire, i certify that i have answered every question and filled in every blank. i further certify that i have asked for assistance in answering every question i was unsure about or did not understand. to the best of my knowledge, the answers to these questions are complete and accurate. in addition, i agree to inform the dentist whenever there is a change in my health status.
I authorize the dentist to release health information about me and information about my dental treatment to other health professionals and to insurance companies. i understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable in full at the time of service unless prior financial arrangements have been approved by the dentist. i further understand that should my account have to be referred to an attorney for collection, i am responsible for all fees and costs incurred therein. a one and one half percent per month service charge will be imposed on account balances due over thirty days. i also authorize any insurance payments may be sent to the attending dentist.