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Park & Rogers Dentistry Stephanie J. Park, D.D.S. Renee L. Rogers, D.D.S.CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT Name: Date of Birth: Address: Telephone:
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Parke & Rogers Dentistry is a dental practice that offers a range of services such as preventive care, restorative treatments, and cosmetic dentistry.
Patients who receive services from Parke & Rogers Dentistry are required to file their own dental insurance claims.
To fill out Parke & Rogers Dentistry forms, patients need to provide their personal information, insurance details, and treatment received.
The purpose of Parke & Rogers Dentistry is to provide high-quality dental care services to patients and help them achieve and maintain good oral health.
Information such as patient's name, date of birth, insurance information, treatment received, and charges incurred must be reported on Parke & Rogers Dentistry forms.
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