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Failure to provide this notice will result in a 60. 00 / hour missed appointment charge. Consent for Treatment/Services I have read the above policies of Appleway Dental Clinics and I acknowledge consent for treatment. Appleway Dental Clinics Welcome to our Office Confidential Patient Information Patient Name Date Last First MI Preferred Name Gender M / F Martial Status Married / Single / Child / Other Birth Date dd/mm/yr // Email Address Phone Home Cell Work Ext Address Street/Box City Prov....
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How to fill out appleway dental form
How to fill out appleway dental form
01
To fill out the Appleway Dental form, follow the steps below:
02
Begin by providing your personal information, such as your name, address, contact number, and date of birth.
03
Fill in your dental insurance details, including the name of your insurance company and your policy or member number.
04
Specify your dental history, including any previous treatments or surgeries you have undergone.
05
If you have any allergies or medical conditions that may affect your dental treatment, make sure to disclose them.
06
Indicate your current dental concerns or issues that you would like the dentist to address.
07
Sign and date the form to confirm the accuracy of the information provided.
08
Return the completed form to the receptionist or dental staff upon your visit to Appleway Dental.
Who needs appleway dental form?
01
Anyone who visits Appleway Dental for dental services needs to fill out the Appleway Dental form. This form helps the dental office to gather essential information about patients, including their personal details, dental insurance information, medical history, and current dental concerns.
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