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Medical Arts Press® Patient Registration and History Form

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Item #: 901-39071
  Model #: 39071
Brand: Medical Arts Press
Medical Arts Press® Patient Registration and History Form
$56.99 Pack
When you buy 8+
250 EACH = 1 PACK
$71.99 Pack
When you buy 1
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Qty 1 2-3 4-7 8+
Price $71.99 $66.99 $59.99 $56.99
Qty. Savings 6% 16% 20%
Price per each: $0.29 $0.27 $0.24 $0.23
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  • Easy-to-complete form guides patient to insert complete Medical History
  • Special sections alert Dentist to certain diagnoses and medication history requiring medical clearance
  • Use with every patient on initial visit. Here are some of the form s features:
  • General patient profile includes employer, person responsible for payment and referral information
  • Patient verifies insurance coverage and responsibility for payment of the remaining balance
  • Authorization for release of Protected Health Information and authorization for treatment
  • Patient specifies any dental-related problems that may be a concern for a first visit
  • Dedicated list of medical conditions requiring medical clearance
  • Expanded list of allergies; Patient certifies accuracy of medical history
  • Size: 8-1/2x11"
True Color : White Width in Inches : 8.5 Business Forms Pack Size : 250 Envelopes : Envelopes Not Included
Brand : Medical Arts Press Customizable : No
Weight : 2.43 lbs. per Pack

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