New Patient Forms

/New Patient Forms
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HEALTH HISTORY

4. Any history of:

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PERSON RESPONSIBLE FOR ACCOUNT

CONSENT FOR TREATMENT/OFFICE POLICY

I consent to all dental procedures discussed with Drs. Benbassat, Goldenberg, or Ramji. I have read, understand and agree with the policies of this office. I assume responsibility for all fees charged for my dental treatment. ALL FEES ARE PAYABLE ON THE DATE OF SERVICE. PAYMENTS MAY BE MADE BY CASH, DEBIT, VISA, MC OR AMEX ONLY. WE DO NOT ACCEPT PERSONAL CHEQUES.

Click to Read Consent for Treatment/Office Policy