Medical History

PRESENT HEALTH (please specify where appropriate)

Office Policy

APPOINTMENTS: Please give a minimum of 24 hours notice if an appointment must be cancelled. This will enable us to see patients who are waiting for appointments at an earlier time.

Patients are personally responsible for payment of fees. We will prepare the necessary reports to enable us or you to be reimbursed by your insurance company. Please note: the degree of reimbursement varies with the company and type of coverage

I authorize release to my Insurance Company's plan administrator, any information necessary to support claims or predeterminations submitted by you the patient or on your behalf by this office.

I authorize you to request or furnish any dental or medical records to a dentist or physician which would help in the diagnosis and treatment of my condition.

I understand that the Privacy Policy of the Westwood Dental /Starwood Dental is available to me for my review at any time.

(if Minor, Parent's Signature)


Westwood Dental requires a minimum of 24 hours to cancel your reserved appointment time. Failure to do so, may result in a $75.00 cancellation fee.