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    New Patient Form



    In Case Of Emergency


    1. Insurance

    2. Insurance

    If someone other than the PATIENT is responsible for payment, complete the following

    By hitting submit:

    I acknowledge that I am financially responsible for all chargers whether or not they are covered by insurance. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the act of submitting agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize the doctor to release treatment information and x-rays.
Submit

Clovis/Fresno Dentistry - K&H Dental Group - 1550 Shaw Ave Clovis Ca 93611 - 559-840-3440

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