New Patient Form

Privacy of your personal information is an important part of our office as is providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and clear as possible about the way in which we handle your personal information. All our staff members who come into contact with your personal information are trained in the appropriate uses and protection of your personal information. I, the undersigned, understand that the data contained in the dental and medical history portion of this chart is important to treatment. I certify that all the information is correct and that I have not knowingly omitted data. I consent to the release of medical information my medical doctor or other health provider as is required by Dana Dental Clinic. I authorize Dana Dental Clinic to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.