Free Family Dentistry Assessment

    Have all members of your family had a dental cleaning in the past 6 months? (Select One)

    Have all members of your family had a dental exam in the past year? (Select One)

    Does any member of your immediate family complain about tooth pain frequently? (Select One)

    Does any member of your immediate family have chipped or broken teeth? (Select One)

    Does any member of your family complain of hot or cold sensitivity to food and beverages? (Select One)

    Provide your name and email to get your results.

    Your privacy is our utmost concern. Your name and email will not be shared with any third party.


    Authorizations and Acknowledgements

    ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

    Private Practices: I (the patient) have the right to read the Privacy Practices. A copy of the Notice and/or this consent is available upon request and anytime on our website. The Notice provides a description of our practice's treatment, payment activities, healthcare operations and the uses and disclosures we make of your protected health information.

    Purpose of Consent: I (the patient) understand and consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

    Personal protected information cannot be shared with anyone unless otherwise allowed by HIPAA rules.

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