For your convenience, we’ve made the forms available here that you’ll need for your first visit with us. You can also access the Membership Enrollment form below and a PDF file of our Privacy Practices for you to review. These forms are also available at our office or by mail if that is more convenient for you. Please let us know how we can best serve you.
FIRST VISIT FORMS:
In order to start your appointment on time, we would appreciate it if you would bring the following to your first visit:
- Completed Patient Financial Information
- Completed Health History or Child Health History (required for children age 6 and under)
- Completed HIPAA Consent of Privacy Form (required for all patients)
- Completed Request for Release of Dental Records
- Proof of identification, such as your Driver’s License
- Any dental insurance card or information
HIPPA PRIVACY FORMS:
Please complete and bring the HIPAA Consent of Privacy Form with you to your first appointment. The HIPAA Notice of Privacy Practices describes how health information about you may be used and disclosed and how you can get access to this information. Please review carefully. The privacy of your health information is important to us.
- HIPAA Consent of Privacy Form (please sign to document that you’ve reviewed the HIPAA Notice of Privacy Practices)
MEMBERSHIP ENROLLMENT FORMS:
No Dental Insurance? No Problem! Complete the Membership Enrollment Form to take advantage of no yearly maximums, no deductibles, no waiting periods, and no rejected claims.