WWW.CONNERDENTISTRY.COMTRANSLATE THIS PAGE www.connerdentistry.com CONNERDENTISTRY.COMTRANSLATE THIS PAGE

connerdentistry.com

CONNERDENTISTRY.COM

Dental & Health History CONFIDENTIAL Patient ID # Your child's overall health as well as any medications which your child takes could have an

important inter-

TERESA BURNS

Teresa Burns. Teresa has been working in the dental profession for eleven years and with Dr. John Conner for four years. She has various responsibilities within the practice. FINANCIAL COMMITMENT AGREEMENT Financial Commitment Agreement Dental treatment is an excellent investment in an individual’s medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service.

CONNER DENTISTRY

ID. First Name. PATIENT REGISTRATION Chart ID. Last Name: Ext: Drivers Lic: Middle Initial Middle Initial. Pager: Cellular. Patient Is: C] Policy Holder DResponsible Party WWW.CONNERDENTISTRY.COMTRANSLATE THIS PAGE www.connerdentistry.com CONNERDENTISTRY.COMTRANSLATE THIS PAGE

connerdentistry.com

CONNERDENTISTRY.COM

Dental & Health History CONFIDENTIAL Patient ID # Your child's overall health as well as any medications which your child takes could have an

important inter-

TERESA BURNS

Teresa Burns. Teresa has been working in the dental profession for eleven years and with Dr. John Conner for four years. She has various responsibilities within the practice. FINANCIAL COMMITMENT AGREEMENT Financial Commitment Agreement Dental treatment is an excellent investment in an individual’s medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service.

CONNER DENTISTRY

ID. First Name. PATIENT REGISTRATION Chart ID. Last Name: Ext: Drivers Lic: Middle Initial Middle Initial. Pager: Cellular. Patient Is: C] Policy Holder DResponsible Party

CONNERDENTISTRY.COM

connerdentistry.com

WWW.CONNERDENTISTRY.COMTRANSLATE THIS PAGE www.connerdentistry.com

TERESA BURNS

Teresa Burns. Teresa has been working in the dental profession for eleven years and with Dr. John Conner for four years. She has various responsibilities within the practice. FINANCIAL COMMITMENT AGREEMENT Financial Commitment Agreement Dental treatment is an excellent investment in an individual’s medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service.

CONNER DENTISTRY

ID. First Name. PATIENT REGISTRATION Chart ID. Last Name: Ext: Drivers Lic: Middle Initial Middle Initial. Pager: Cellular. Patient Is: C] Policy Holder DResponsible Party 556 North Cass Street Wabash, IN 46992 | 260-563-4805

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Our mission is quite simple. We treat our patients the way we ourselves want to be treated — with compassion and integrity. Dr. Conner and his team are knowledgeable, respectful, detail oriented, caring, and very personable. Whether it is fear or sensitivity, we take special interest in helping everyone.

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