Visit Us: 9320 Annapolis Road, Suite 101 Lanham MD 20706

Dental Registration and History


    Patient Information


    Employment History

    Dental Insurance



    Assignment and Release

    I certify that I, and/or my dependent(s), have insurance coverage with the insurance companies listed above in this form, and assign directly to Dr. George all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

    The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

    Contact Phone Numbers

    In case of Emergency, Contact (Specify someone who does not live in your household)


    Dental History

    Indicate if you have had any of the following:

    Health History

    Indicate if you have had any of the following:

    Women Only


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