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IMPORTANT: If you are a new patient and this is your first time visiting Dr. Sophia Nichols, please fill out in advance and bring to your visit.

    • ABOUT YOUR CHILD


    • DENTAL INSURANCE COMPANY #1

    • This Dental Insurance is provided through:
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    • ABOUT YOU

    • DENTAL INSURANCE COMPANY #2

    • This Dental Insurance is provided through:
    • DENTAL /MEDICAL HISTORY

    • Has your child ever had any of the following medical conditions or problems?

    • In the event of an emergency, whom should we contact?
    • I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services by child may need. The Parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved.
    • (please print out and sign)
    • THANK YOU for filling out this form completely. It will enable us to give your child the best dental care possible. If you or your child have any questions, please feel free to ask us at any time.
       

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