UPDATE TO REGISTRATION AND MEDICAL HISTORYTo assist us in serving you, please complete the following confidential form. The information provided is important to your dental health.
If Yes, please fill out the section below and inform our front desk with your insurance card to update and expedite your visit.
By signing below, I authorize the release of any dental or other information necessary to process my claims. I also authorize payment of dental benefits to be made to Bello-Burgos Smiles.
Have you ever had
Have you ever Experienced
Indicate which of the following you have had or have
I certify and understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered these questions truthfully to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication. For this, I will not hold my dentist, or any other member of their staff responsible for any errors or omissions that I may have made in the completion of this form.