Fwgentlecare.com

About us – Gentle Care Family Dentistry, Fort Wayne – 46804

WEBDentist. Dr.Boateng, originally from Ghana, West Africa, moved to the states in 2002 to attend college. He graduated from Westminster college in Missouri in 2006. He furthered …

Actived: 8 days ago

URL: https://www.fwgentlecare.com/about-us/

PATIENT REGISTRATION

WEBPATIENT REGISTRATION Today’s Date Patient’s Name Sex: M F Date of Birth Age Home Address City State ZIP Please Circle One: Single Married

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PATIENT REGISTRATION

WEBPATIENT REGISTRATION Today’s Date Patient’s Name Sex: M F Date of Birth Age Home Address City State ZIP Please Circle One: Single Married

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GENTLE CARE FAMILY DENTISTRY NOTICE OF PRIVACY …

WEBgentle care family dentistry notice of privacy practices ----- this notice describes how health informtion about you may be used and disclosed

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PORY yald whiten vour t

WEBDENT AL HISI If PORY yald whiten vour t ceth for a cost Yes that apply to yc -Sensitivitv Whereo -Headaches. ca -Jaw joint lhot: cold. sweet. raches. neck pain

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anvone Do vou If coui -Muk

WEBDENT AL HISI If PORY whiten vour t ceth for a cost Yes that apply to yc -Sensitivitv Whereo -Headaches. ca -Jaw joint lhot: cold. sweet. raches. neck pain

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MEDICAL HISTORY Patient Name (please print) Yes No Yes No …

WEBMEDICAL HISTORY Patient Name (please print) _____ Yes No Yes No Yes No Yes No AIDS Allergies (Seasonal) Anemia Angina (Chest Pain) Anxiety/Nervousness Arthritis …

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