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New Patient Intake Form
Your cooperation in completing this questionnaire is essential to provide you with safe and appropriate dental care. All information is strictly confidential. A member of our team will be able to assist you with the completion of this form.
Please list any other persons who may have access to this file
(e.g. scheduling appointments)
If you have secondary insurance, please complete this section
By signing this document, I confirm that all answers I have given above are true to the best of my knowledge.