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New Patient Form Additional Adult

Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply.

  • MM slash DD slash YYYY
  • Patient Medical History

  • Patient Dental History

  • Upload a Photo

  • Max. file size: 50 MB.
  • I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that South Airdrie Smiles can electronically file dental claims on my behalf.

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