Your personal details. Please review them and make any necessary adjustments.
In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health History have a important relationship with your Dental Treatment. Please answer the following question.
The information I have given above is true to the best of my knowledge.
I acknowledge and understand payment is due in full at the time of treatment unless prior arrangements have been approved.
This office accepts insurance so I understand that I am responsible for payment of services rendered and
also responsible for paying any co-payment and deducible that my insurance does not cover. I hereby
authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I
understand that I am responsible for all costs of dental treatment. I hereby authorize release of any
information, including the diagnosis and records of treatment or examination rendered, to my insurance
I UNDERSTAND THAT GREYSTONE FAMILY DENTAL HAS A 2 DAY CANCELLATIION POLICY. IF AN
APPOINTMENT IS CHANGE OR CANCELLED WITHOUT 2 BUSINESS DAYS NOTICE THERE WILL BE A FEE