To help us meet all your health care needs, please fill out this form completely.
If you have any questions, please call or email us and we will be happy
Are you allergic or have you had any reactions to the following:
a. Local Anesthetics
Have you ever been hospitalized for any surgical operation or serious
illness within the last 3 years?
If yes, please explain:
company to pay directly to Dr. Walker/Dr. Brecht or dental group insurance
benefits otherwise payable to me. I understand that my dental insurance
carrier may pay less than the actual bill for services. I agree to
be responsible for payment of all service rendered on my behalf or