• Patient Registration

  • Medical History

  • The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions I may have made in the completion of this form. I understand I am being treated by an independent contractor and will hold Nikhita Shree Kumar, INC. and Consumer Dental Care Center harmless.