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    Date:

    Birth Date:

    Sex:

    Status:

    In Case Of Emergency Contact:

    Primary Insurance

    Individual responsible for this account

    Birth Date

    Additional Insurance

    Individual responsible for this account

    Birth Date

    Assignment And Release

    I, the undersigned certify that I (or my dependent) have insurance coverage with Lakeside Family Dental and assign directly to Dr. Arman Nazir all insurance benefits, for any services provided me. I authorize any holder of medical and other information about me to release to Lakeside Family Dental Group and its agents, any information needed to determine these benefits or benefits for related services. I agree to pay for all charges not covered by a third party payer. I authorize a copy of this authorization to be used in place of the original. In order to ensure proper follow-up and continuity of care, I agree that a copy of my medical record may be released to my physician, a designated referral physician, and/or the provider, If any, who referred me here. I expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits for services rendered or for services to be rendered without obtaining my signature on each and every claim submitted.

    Date:

    Signature

    Family Health Information

    Some health conditions are the result of hereditary spinal weaknesses. Information that you can furnish us pertaining to your immediate family members (brothers, sisters, parents and grandparents) will give us a better understanding of your total health needs.

    Medications

    Check Any Symptom(s) Or Condition(s) Below That You Currently Have or Have Had In The Past Year:

    Check Degree of Habits Below. All Information Will Be Kept Strictly Confidential.

    Some health conditions are the result of hereditary spinal weaknesses. Information that you can furnish us pertaining to your immediate family members (brothers, sisters, parents and grandparents) will give us a better understanding of your total health needs.

    Alcohol

    Appetite

    Artificial Sweeteners

    Coffee

    Drugs

    Exercise

    Salty Foods

    Sleep

    Soft Drinks

    Sugar/Sugar Product

    Tobacco

    Water

    I certify that the above information is correct to the best of my knowledge. I will not hold any dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

    Date:

    Signature