Dental Registration and History

Please fill out this form in its entirety. If you prefer to print a copy of this form to fill out by hand, you may do so by downloading the PDF version. Please bring it with you to your appointment or mail it in ahead of time.

Patient Information

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Dental Insurance

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Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with
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and assign directly to Waterville Community Dental Center 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/dental center 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.

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Phone Numbers

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

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Place a mark on "yes" or "no" to indicate if you have had any of the following:

 

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Health History

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Place a mark on "yes" or "no" to indicate if you have had any of the following:
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Women
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Medications

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Allergies

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Hours

7:30am – 5pm Mon.

7:30am – 5pm Tue.

7:30am – 5pm Wed.

7:30am – 5pm Thu.

Contact Us

Waterville Community Dental Center

2 Evergreen Drive
Oakland, ME 04963

(207) 861-5801
Email Us