ADULT MEDICAL HISTORY FORMS
BRIARCLIFF SMILE DESIGN
It is important that you schedule your appointment first and then fill up the medical history forms part 1 and part 2 both.
I understand that the information that I have given today in the strictest confidence and it is my responsibility to inform Briarcliff Smile Design dental office of any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
If Briarcliff Smile Design Dental office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my Insurance does not cover.
Payment is due in full at the time of treatment unless prior arrangements have been approved.
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Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. Please read about HIPPA COMPLIANCE HERE.