MEDICAL HISTORY


Have you ever had any of the following?

Please check all that apply


PERSON RESPONSIBLE FOR PAYMENT


If you are a parent bringing a minor, the signer of the registration and financial agreement will be listed as the responsible party.
(If you are 18 years of age or older you are the person responsible and signing all forms.)


INSURANCE INFORMATION


Medical / Dental Insurance is a contract between the insured and the insurance carrier. The patient is responsible to our office for the total fees charged for services rendered. We are happy to bill your insurance company as a service to you if you supply us with the necessary information

St. George Office

435.673.1554

1308 East 900 South Saint George, Utah 84790

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Monday-Thursday: 8:30am-5:00pm Friday: 7:30am-1:00pm

Cedar City Office

435.867.1474

415 N. Main Street, Ste. 204 Cedar City, Utah 84721

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Monday-Thursday: 8:30am-5:00pm Friday: 7:30am-1:00pm