Patient Form English

I certify that I have read and understand the above information to the best of my knowledge. I understand that providing false information can be dangerous to my health. I authorize the dentist to release information including diagnosis and records of treatment rendered to me or dependent to a third party payee &/or health practitioners. I authorize and request my insurance company to pay directly to Dr. Hornberger/East County Endodontics. I understand that the insurance information provided to me is an estimate only and not a guarantee of payment. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Patient Information

Patient Medical History

Are you allergic to any of the following?

Patient's history of health problems

Referring Dental Office Information

Method Of Payment