Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.
Please share with us any health problems
that you may have, or medication that you may be taking.
To the best of my knowledge, the questions on this form have been
accurately answered. I understand that providing incorrect information can
be dangerous to
my (or patient’s) health. It is my responsibility to inform the dental
office of any changes in medical status.
I agree to be responsible for the payment of all services rendered on my
behalf or my
dependents. I am aware that all balances over 90 days will be accessed a
In the case that I have dental insurance, I authorize and request
my insurance company to pay
directly to Clearwater Dental, otherwise payable to me. I understand that my
carrier may pay less than the actual bill for services. Therefore; I am
responsible for any