Fort Cosmetic and Family Dentistry – Owensboro, KY Dental Care New Patient Registration - Fort Cosmetic and Family Dentistry

Acknowledgement and Verification of Information
Acknowledgement and Verification*
- The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or/and any member of his staff responsible for any errors or omissions that I may have made in the completion of this form.
Electronic Signature*
Signature of Patient, Parent, or Guardian. Please enter first and last name.

Authorization of Medical History
Authorization*
- 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 my patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Electronic Signature*
Signature of Patient, Parent, or Guardian. Please enter first and last name.
Phone

This field is for validation purposes and should be left unchanged.

New Patient Registration