Robert W. Payne, D.D.S.

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Demographic Information

PATIENT INFORMATION

Emergency Contact

BILLING INFORMATION (IF SAME AS ABOVE LEAVE BLANK)

FEES & PAYMENTS

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Dental History

Dental History

Do you have or have you ever had any of the following

Medical History

Medical History

Do you have, or have you ever had, any of the following conditions

Family Medical History - Do you have a family history of any of the following conditions?

Medications

Medications - Are you currently prescribed or taking any of the following

Medications (continued)

Medication and dose

Allergies

Allergies - Are you allergic to or have you had an adverse reaction to

Anesthesia History

Female Patients

Social History

Pharmacy Information

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Controlled Substance Prescribing

Controlled Substance Prescribing

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Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

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