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New Mexico Dental Clinics Llc

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NEW MEXICO DENTAL CLINICS LLC

This form is used to obtain consent from patients for dental procedures.

Patient Information

Please provide the following information about yourself.

Email*

Full Name*

Date of Birth*

Address*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Description:This is a patient consent form for New Mexico Dental Clinics LLC. By signing this form, you give your consent for the dental clinic to provide you with dental treatment and services. The form also includes information about the risks and benefits of the treatment, as well as your rights as a patient.

As a patient of New Mexico Dental Clinics LLC, it is important that you understand the treatment and services that you will be receiving. This patient consent form outlines the details of your treatment plan, including the risks and benefits of the procedures. By signing this form, you give your consent for the dental clinic to provide you with the necessary treatment and services. The form also includes information about your rights as a patient, such as your right to privacy and your right to access your medical records. If you have any questions or concerns about your treatment plan or this consent form, please do not hesitate to speak with your dentist or another member of the dental clinic staff.

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Last Name*

Date of Birth*

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First Name*

Last Name*

Phone Number*

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Patient's Full Name*

Patient's Date of Birth*

Patient's Address*

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Patient Name*

Patient ID*

Date of Birth*

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Full Name*

Employee ID*

Date of Birth*

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