Craig R. Yoder
Click Here (Patient Information/Health History) to download a printable copy of the form in PDF format.
Please fill in as many fields as possible. All fields marked with an asterisk (*) are required.
Female / Male: MaleFemale
If you have no telephone, please list a telephone number of a neighbor.
Marital Status (Select One) : SingleMarriedWidowedDivorced
Do you have dental insurance? YesNo
(If Yes, please complete the following insurance questions)
Have you ever had any of the following? Please Check YES or NO for Every* question.
Breast feeding? YesNo
(Signature of Patient, if adult. If Patient is under 18 years of age, parent or guardian must sign.)
I understand that I am responsible for my account regardless of my dental benefit plan. I also understand that my dental benefit plan is an agreement between me and my dental benefit plan company.
I understand that I may be charged a 1.5% finance charge per month (18% Annually) if my balance goes beyond 90 days.
I give permission for my dentist and clinical team to take any necessary radiographs and study models to make a complete diagnosis of my dental needs.
You must 'check' the acceptance box in order to submit your information.
I have read, agree to and understand the statements listed above.